in the united states district court northern district...
TRANSCRIPT
IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF FLORIDA
Pensacola Division
Case No.: 3:10-cv-91-RV/EMT
STATE OF FLORIDA, by and through BILL McCOLLUM, ATTORNEY GENERAL OF THE STATE OF FLORIDA; STATE OF SOUTH CAROLINA, by and through HENRY McMASTER, ATTORNEY GENERAL OF THE STATE OF SOUTH CAROLINA; STATE OF NEBRASKA, by and through JON BRUNING, ATTORNEY GENERAL OF THE STATE OF NEBRASKA; STATE OF TEXAS, by and through GREG ABBOTT, ATTORNEY GENERAL OF THE STATE OF TEXAS; STATE OF UTAH, by and through MARK L. SHURTLEFF, ATTORNEY GENERAL OF THE STATE OF UTAH; STATE OF LOUISIANA, by and through JAMES D. “‘BUDDY”‘ CALDWELL, ATTORNEY GENERAL OF THE STATE OF LOUISIANA; STATE OF ALABAMA, by and through TROY KING, ATTORNEY GENERAL OF THE STATE OF ALABAMA; MICHAEL A. COX, ATTORNEY GENERAL OF THE STATE OF MICHIGAN, ON BEHALF OF THE PEOPLE OF MICHIGAN; STATE OF COLORADO, by and through JOHN W. SUTHERS, ATTORNEY GENERAL OF THE STATE OF COLORADO; COMMONWEALTH OF PENNSYLVANIA, by and through THOMAS W. CORBETT, Jr.,
ATTORNEY GENERAL OF THE COMMONWEALTH OF PENNSYLVANIA; STATE OF WASHINGTON, by and through ROBERT M. McKENNA, ATTORNEY GENERAL OF THE STATE OF WASHINGTON; STATE OF IDAHO, by and through LAWRENCE G. WASDEN, ATTORNEY GENERAL OF THE STATE OF IDAHO; STATE OF SOUTH DAKOTA, by and through MARTY J. JACKLEY, ATTORNEY GENERAL OF THE STATE OF SOUTH DAKOTA; STATE OF INDIANA, by and through GREGORY F. ZOELLER, ATTORNEY GENERAL OF THE STATE OF INDIANA; STATE OF NORTH DAKOTA, by and through WAYNE STENEJHEM, ATTORNEY GENERAL OF THE STATE OF NORTH DAKOTA; STATE OF MISSISSIPPI, by and through HALEY BARBOUR, GOVERNOR OF THE STATE OF MISSISSIPPI; STATE OF ARIZONA, by and through JANICE K. BREWER, GOVERNOR OF THE STATE OF ARIZONA; STATE OF NEVADA, by and through JIM GIBBONS, GOVERNOR OF THE STATE OF NEVADA; STATE OF GEORGIA, by and through SONNY PERDUE, GOVERNOR OF THE STATE OF GEORGIA; STATE OF ALASKA, by and through DANIEL S. SULLIVAN, ATTORNEY GENERAL OF THE STATE OF ALASKA; NATIONAL FEDERATION OF INDEPENDENT BUSINESS, a California nonprofit mutual benefit corporation;
MARY BROWN, an individual; and KAJ AHLBURG, an individual; Plaintiffs, v. UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES; KATHLEEN SEBELIUS, in her official capacity as the Secretary of the United States Department of Health and Human Services; UNITED STATES DEPARTMENT OF THE TREASURY; TIMOTHY F. GEITHNER, in his official capacity as the Secretary of the United States Department of the Treasury; UNITED STATES DEPARTMENT OF LABOR; and HILDA L. SOLIS, in her official capacity as Secretary of the United States Department of Labor, Defendants. ___________________________________________/
PLAINTIFFS’ MEMORANDUM IN OPPOSITION TO DEFENDANTS’ MOTION FOR SUMMARY JUDGMENT
i
TABLE OF CONTENTS
Table of Authorities................................................................................................................ iii Introduction ...............................................................................................................................1 Argument ..................................................................................................................................6
I. THE INDIVIDUAL MANDATE IS UNCONSTITUTIONAL .............................. 6 A. The Commerce Power Has Limits That Congress Must Respect ............... 6 B. The Commerce Power Does Not Support the Individual Mandate .............. 7 1. The Commerce Power Does Not Regulate the Health Care Services Market .......................................................................................... 8 2. The Commerce Power Only Reaches Activity ........................................ 8 3. Inactivity Cannot Be Redefined as “Economic Activity” ..................... 10 4. Defendants Can Identify No Meaningful Limiting Principle ................ 13 5. Limiting the Commerce Power to Commercial Activities is a Necessary Constraint on Congress .......................................................... 14 6. Only a Forbidden Police Power Could Support the Mandate ............... 15 C. The Mandate Cannot Be Saved by the Necessary and Proper Clause ..... 18 1. The Individual Mandate Fails under the Comstock Factors ................. 18 2. The Mandate Is Not “Essential” to a Larger and Legitimate
Regulatory Scheme .................................................................................. 19 3. The Mandate Is Too Remote from the Insurance Regulations It
Supposedly Supports ............................................................................... 22 D. That No Previous Congress Believed the Commerce Power to
Support Enactment of Individual Mandates Negates Such a Power’s Existence ...................................................................................................... 24
ii
II. THE ACA’S MEDICAID TRANSFORMATION IS UNCONSTITUTIONAL .......................................................................................... 27
A. Defendants Cannot Dispute the ACA’s Significant Alterations to
Medicaid ...................................................................................................... 30 B. The ACA’s Transformation of Medicaid Harms the Plaintiff States’
Budgets and Sovereignty ............................................................................ 33 1. Plaintiffs’ Coercion Claim Is Not Undermined By Increased
Federal Spending on Medicaid under the ACA ..................................... 33 2. Increases in State Spending Will Not Be Offset By New Savings
Under the ACA ........................................................................................ 38 C. Plaintiffs States’ Coercion Claim Is Justiciable and Fit for Judicial
Resolution in Plaintiffs’ Favor ................................................................... 42 D. The ACA’s Medicaid Program Is Unlawfully Coercive ........................... 44 E. The ACA Violates All Five Dole Spending Clause Restrictions ...............48
III. THE UNCONSTITUTIONALITY OF THE ACA’s MEDICAID REGIME REQUIRES THAT THE ENTIRE ACT BE STRUCK DOWN ........................... 49
CONCLUSION ......................................................................................................................50
CERTIFICATE OF SERVICE ..............................................................................................52
iii
TABLE OF AUTHORITIES Cases
Alabama-Tombigbee Rivers Coal. v. Kempthorne, 477 F.3d 1250 (11th Cir. 2007) ...........................................................................................13 Alabama Power Co. v. U.S. Dep’t of Energy, 307 F.3d 1300 (11th Cir. 2002) ...........................................................................................49 Alaska Airlines, Inc. v. Brock, 480 U.S. 678 (1987) .............................................................................................................50 Ayotte v. Planned Parenthood of N. New England, 546 U.S. 320 (2006) ...................................................................................................... 49, 50 Brockett v. Spokane Arcases, 472 U.S. 491 (1985) .............................................................................................................49 College Sav. Bank v. Fla. Prepaid Postsecondary Educ. Expense Bd., 527 U.S. 666 (1999) ................................................................................................ 42, 44, 47
Garcia v. Vanguard Car Rental USA, Inc., 540 F.3d 1242 (11th Cir. 2008) ................................................................................ 7, 10, 13 Gibbons v. Ogden, 22 U.S. 1 (1824) ................................................................................................................ 6, 9 Gonzales v. Raich, 545 U.S. 1 (2005) ......................................................................................................... passim
Harris v. McRae, 448 U.S. 297 (1980) .............................................................................................................30
Heart of Atlanta Motel v.United States, 379 U.S. 241 (1964) .............................................................................................................12 Hill v. Wallace, 259 U.S. 44 (1922) ...............................................................................................................50 In re: Heritage Propane, 2007 U.S. Dist LEXIS 88933 (E.D. Tenn. Feb. 6, 2007) ..................................................16
iv
In re: Quarles, 158 U.S. 532 (1895) .............................................................................................................16 Jacobson v. Massachusetts, 197 U.S. 11 (1905) ...............................................................................................................15 Kelo v. City of New London, 545 U.S. 469 (2005) .............................................................................................................17 Luxton v. North River Bridge Co., 153 U.S. 525 (1894) .............................................................................................................17 Marbury v. Madison, 5 U.S. 137 (1803) ........................................................................................................ 2, 7, 14
McCulloch v. Maryland, 17 U.S. 316 (1819) ...............................................................................................................21 Mejia v. City of New York, 119 F. Supp. 3d 232 (E.D.N.Y 2000)..................................................................................16 NLRB v. Jones & Laughlin Steel Corp., 301 U.S. 1 (1937) ...................................................................................................................9 Nevada v. Skinner, 884 F.2d 445 (9th Cir. 1989) ...............................................................................................46 New York v. United States, 505 U.S. 144 (1992) ...................................................................................................... 15, 48
Printz v. United States, 521 U.S. 898 (1997) ................................................................................................ 25, 27, 48 Selective Draft Law Cases, 245 U.S. 366 (1918) .............................................................................................................16 South Dakota v. Dole, 483 U.S. 203 (1987) ..................................................................................................... passim
Steward Mach. Co. v. Davis, 301 U.S. 548 (1937) ................................................................................................. 34, 42-43
Thomas More Law Ctr. v. Obama, 2010 WL 3952805 (E.D. Mich. Oct. 7, 2010) ....................................................................10
v
United States v. Ambert, 561 F.3d 1202 (11th Cir. 2009) ...........................................................................................13
United States v. Belfast, 611 F.3d 783 (11th Cir. 2010) .............................................................................................13 United States v. Butler, 297 U.S. 1 (1936) .................................................................................................................34 United States v. Comstock, 130 S. Ct. 1949 (2010) ................................................................................................. passim United States v. Darby, 312 U.S. 100 (1941) .............................................................................................................19 United States v. Gould, 568 F.3d 459 (4th Cir. 2009) ...............................................................................................13 United States v. Lopez, 514 U.S. 549 (1995) ..................................................................................................... passim United States v. Maxwell, 446 F.3d 1210 (11th Cir. 2006) ...........................................................................................13 United States v. Morrison, 529 U.S. 598 (2000) ........................................................................................................ 6, 15 United States v. Olin Corp., 107 F.3d 1506 (11th Cir. 1997) ...........................................................................................13 United States v. Williams, 121 F.3d 615 (11th Cir. 1997) .............................................................................................13 Wickard v. Filburn, 317 U.S. 111 (1942) ...................................................................................................... 12, 24
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CONSTITUTIONAL PROVISIONS U.S. Const. art. I, § 8, cls. 2, 3, 4, 5, 6, 7, 8, 9 ......................................................................14 U.S. Const. art. I, § 8, cl. 3 (Commerce Cl.)................................................................. passim U.S. Const. art. I, § 8, cl. 18 (Necessary & Proper Cl.) ............................................... passim
STATUTES
2 U.S.C. § 166(d)(1) ...............................................................................................................25 2 U.S.C. § 602(a) ....................................................................................................................25 15 U.S.C. § 78i(a) ...................................................................................................................25 21 U.S.C. § 62.........................................................................................................................25 21 U.S.C. § 331(a) ..................................................................................................................26 29 U.S.C. § 212(a) ..................................................................................................................25 42 U.S.C. § 4001 (Nat’l Flood Ins. Act) ...............................................................................26 42 U.S.C. § 4012a(a)(b) & (e) ...............................................................................................27 42 U.S.C. § 9607(a) (CERCLA)............................................................................................17 Patient Protection and Affordable Care Act (“ACA”), Pub. L. No. 111-148, 124 Stat. 119 (2010)
§ 1501(a)(2)(D) ................................................................................................................20 § 1501(a)(2)(G) ................................................................................................................23 § 1501(a)(2)(H) ................................................................................................................23 § 2304 ...............................................................................................................................30
OTHER AUTHORITIES
Andrew L. Yarrow, State Budget Crises Mount as Medicaid Rolls Soar, The Fiscal Times, Sept. 8, 2010 .................................................................................... 36-37
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Anna Sommers, Medicaid Enrollment and Spending by “Mandatory” and “Optional” Eligibility and Benefit Categories, Kaiser Comm’n on Medicaid & the Uninsured, June 2005 .............................................................................................. 29, 32 Ben S. Bernanke, Chair, Bd. of Governors of the Fed. Reserve Sys., Challenges for the Economy and State Governments, Aug. 2, 2010 ......................................... 35, 36, 47
Bipartisan Comm’n on the Medicaid Act of 2005, H.R. 985, 109th Cong. § 2(13) (2005) ......................................................................................................................43
Centers for Medicare & Medicaid Servs., Justification of Estimates for Appropriations Committees, FY 2011 ................................................................................. 46 Centers for Medicare & Medicaid Servs., Medicaid Spending Projected to Rise Much Faster Than the Economy, Oct. 17, 2008 ................................................................. 35 Centers for Medicare & Medicaid Servs., National Health Expenditure Projections 2009-2019 ................................................................................................... 34-35 Charles A. Perry, Significant Floods in the United States During the 20th Century -- USGS Measures a Century of Floods (Mar. 2000) ........................................................ 26 Christina D. Romer, Chair, Council of Economic Advisors, Back to a Better Normal: Unemployment and Growth in the Wake of the Great Recession, April 17, 2010 ....................................................................................................................... 46
Citizen’s Guide to the Federal Budget, http://www.gpoaccess.gov/usbudget/fy01/guide02.html ..................................................44 Cong. Budget Off., The Long-Term Budget Outlook, June 2010 (“CBO Budget Outlook”) ............................................................................................. 35, 44
Cong. Budget Off., Payments of Penalties for Being Uninsured Under the Patient Protection and Affordable Care Act, April 22, 2010 ......................................................... 39 Cong. Budget Off., Policies for Increasing Economic Growth and Employment in 2010 and 2011, Jan. 2010 ............................................................................................. 35, 47
Cong. Research Serv., Variation in Analyses of PPACA’s Fiscal Impact on States, Sept. 8, 2010 ............................................................................................................. 39-40, 41
Council of Economic Advisors, The Impact of Health Insurance Reform on State and Local Governments, Sept. 15, 2009 ................................................................... 5, 38-40
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Gov’t Accountability Office, State and Local Governments’ Fiscal Outlook (GAO-10-358), March 2010 ............................................................................................... 36 Gov’t Accountability Office, State and Local Governments: Fiscal Pressures Could Have Implications for Future Delivery of Intergovernmental Programs (GAO-10-899), July 2010 .................................................................................................... 36 Grant S. Nelson and Robert J. Pushaw, Jr., Rethinking the Commerce Clause: Applying First Principles to Uphold Federal Commercial Regulations but Preserve State Control over Social Issues, 85 Iowa L. Rev. 1 (1999) ............................... 9 http://www.census.gov/govs/statetax/0910flstac.html .........................................................46 http://www.irs.gov/taxstats/article/0,,id=206488,00.html ...................................................46 http://www.hhs.gov/recovery/statefunds.html ......................................................................43 http://www.statehealthfacts.org/comparereport.jsp?rep=45&cat=17 .................................43
Janet Adamy, Medicaid Stalemate Tests Cash-Strapped States, Wall. St. J., July 13, 2010 .................................................................................................... 37 Jennifer Staman & Cynthia Brougher, Requiring Individuals to Obtain Health Insurance: A Constitutional Analysis (CRS Report No. R40725, July 2009) ................. 25 Kaiser Comm’n on Medicaid & the Uninsured, State Fiscal Conditions & Medicaid, Feb. 2010 ..................................................................................................... 35, 37
Katherine Baicker & Amitabh Chandra, Myths and Misconceptions about U.S. Health Insurance, 27 Health Affairs w533 (2008) ........................................................... 22 National Weather Service, Flood Losses: Compilation of Flood Loss Statistics, http://www.nws.noaa.gov/hic/flood_stats/Flood_loss_time_series.shtml ........................ 26 Noah Webster, An American Dictionary of the English Language (1828) .......................... 9
Randy E. Barnett, Commandeering the People: Why the Individual Health Insurance Mandate is Unconstitutional, NYU J.L. & Liberty (forthcoming) .......... 16-17 Randy E. Barnett, The Original Meaning of the Commerce Clause, 68 U. Chi. L. Rev. 101 (2001) ..................................................................................................................... 9
ix
Remarks by the President at Signing of the Health Insurance Reform Bill, http://www.whitehouse.gov/the-press-office/remarks-president-and-vice- president-signing-health-insurance-reform-bill, March 23, 2010 ..................................... 20 Richard S. Foster, Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” as Amended, CMS, April 22, 2010 ........................................ 39, 40 Robert Hartman & Paul Van de Water, The Budgetary Treatment of an Individual Mandate to Buy Health Insurance, CBO, August 1994 .................................................... 25 Romer on Health Care Costs: “The Nightmare Scenario is Getting Closer,” http://blogs.abcnews.com/politicalpunch/2009/06/romer-on-health-care-costs- the-nightmare-scenario-is-getting-closer.html, June 2, 2009 ............................................ 38
Samuel Johnson, A Dictionary of the English Language (J.F. Rivington, et al., eds.) 6th ed. 1785 ................................................................................................................... 9
1
Plaintiffs hereby submit this memorandum in opposition to Defendants’ Motion
for Summary Judgment. As shown below – and as supported by Plaintiffs’ Response to
Defendants’ Statement of Material Facts (“PRSOMF”) and Supplemental Appendix
(“Pl.Supp.App.”), as well as the materials previously submitted in support of Plaintiffs’
Motion for Summary Judgment – Defendants are not entitled to judgment in their favor
on any claims in the Amended Complaint. Accordingly, their motion must be denied.
Introduction
As Plaintiffs have shown in their Motion for Summary Judgment [Doc. 80-1], the
Patient Protection and Affordable Care Act1
A. The Individual Mandate Exceeds the Commerce Power
(“ACA” or “the Act”) exceeds Congress’s
powers under Article I and violates the Ninth and Tenth Amendments. To sustain the
Act, Defendants ask the Court to rewrite the Constitution and fundamentally alter the
relationships between the federal government and the States and between the federal
government and the American people. The Court should refuse this invitation.
The Individual Mandate is unprecedented. It compels citizens to engage in
commerce even though they have not themselves chosen to enter the marketplace.
Never before has Congress purported to use its power over interstate commerce to
compel activity, rather than to regulate existing economic activity. Nor has Congress
ever suggested that such compulsion was “necessary” or “proper” for the regulation of
interstate commerce. Moreover, prior to the ACA’s enactment, no federal court ever had
1 Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010).
2
endorsed the expansive view of the Commerce Clause and Necessary and Proper Clause
on which Defendants’ efforts to justify the mandate depend. Mem. Op. [Doc. 79] at 61.
Limiting the commerce power to the regulation of existing commercial activity,
whether the activity is directly in or has a substantial effect on interstate commerce,
provides a necessary and judicially manageable restraint on congressional authority – a
restraint grounded in the text and history of the Constitution, as well as binding
precedent. Although Defendants demand that the Court abandon this time-tested
limitation on Congress’s authority to regulate “Commerce ... among the several States,”
they can offer no substitute limiting principle that would prevent the Commerce and
Necessary and Proper Clauses from becoming the very sort of general police power the
Framers specifically denied to the federal government.
Moreover, such a ruling impermissibly would render numerous other powers of
Congress redundant and limitations on Congress unavailing. This Court should not
endorse a boundless expansion of federal power so at odds with the basic language and
premises of the Constitution, its historical protection of the rights of the States and the
People vis-à-vis the federal government, and the axiomatic rules of constitutional
construction dating back to Marbury v. Madison, 5 U.S. (1 Cranch) 137 (1803).
B. The ACA’s Medicaid Regime Impermissibly Coerces and Commandeers the States
The ACA further violates the Constitution by coercing the States’ participation in
its new Medicaid regime and by commandeering their resources to achieve the federal
government’s ends. The federal-State Medicaid partnership does not confer plenary
power on the federal government to make any Medicaid revisions that it wishes,
3
irrespective of coercion or harm to the States. Where Medicaid was created as a federal-
State partnership to provide funding to reimburse the healthcare costs of the poor and
needy, the ACA scuttles that partnership and imposes a vastly transformed Medicaid on
the States. Now, Medicaid funding is to be made available to everyone with an income
up to 38 percent above the federal poverty level; the States (but not the federal
government) are to assume responsibility for the provision of healthcare services (rather
than merely reimbursing the costs of those services); and the States’ flexibility to alter
eligibility criteria and to control costs through the withdrawal of optional benefits –
comprising more than 60 percent of Medicaid spending – has been removed. The ACA’s
Medicaid changes are forecast – by federal agencies tasked with scoring the ACA’s
projected impact, by States, and by another respected healthcare organization – to cost
the States at least $20 billion by 2019, and more likely double that figure, not counting
their added administrative overhead or the cost to them from becoming responsible for
providing healthcare services. PRSOMF ¶¶ 40, 47. Indeed, the latter cost alone could
bankrupt States, which probably explains why Congress refused to share that new burden.
These greatly increased costs are imposed at a time when, by the federal government’s
own reckoning, the States must decrease their Medicaid outlays to avoid insolvency.
Congress’s top-down transformation of Medicaid was done to advance the ACA’s
overarching goal of achieving near-universal healthcare insurance coverage. The
Individual Mandate requires that virtually every American must obtain qualified
coverage, and the Act provides four primary “doors” through which a person may pass to
get that coverage: Medicaid, Medicare, statewide insurance exchanges, and employer
4
plans. Congress’s overhaul of Medicaid widens that “door” considerably, in order to
accommodate about 18 million (30 percent) more enrollees. PRSOMF ¶ 43.
Defendants ask the Court to believe that Medicaid remains purely voluntary, and
that any State may simply withdraw to avoid the new costs and burdens. However, there
is no mechanism under law for such a withdrawal – much less for an orderly transition
that would not jeopardize the health and lives of the millions of poor and needy who
depend on the States’ Medicaid programs. Defendants’ contention is especially
disingenuous, because Congress very well knew in passing the ACA that withdrawal
would not be a viable alternative for the States. The ACA’s architecture inherently
depends on the States remaining in Medicaid. A withdrawal would tear a gaping hole in
the ACA’s scheme, locking shut the “door” by which the Act provides for 70-80 million
lower-income Americans to comply with the Individual Mandate; no federal provision is
made to fund their healthcare needs except through Medicaid. States’ withdrawal not
only would frustrate the ACA’s universal coverage objective, but would end up leaving
the poorest and neediest out in the cold even while federal subsidies would be lavished on
millions of other persons at far higher income levels.
Defendants’ remaining contentions are specious. First, they note that the federal
government will be spending more under the new Medicaid regime than will the States.
But the level of the federal government’s contribution fails to address the substantial new
costs and burdens placed on the States. Moreover, likening federal and State fiscs is akin
to comparing apples and oranges, because the States – unlike the federal government –
5
cannot tax at rates equal to the federal government, cannot print money to cover their
debts, and cannot pile up deficits the size of the federal government’s.
Second, Defendants offer the preposterous claim that the States will achieve net
savings under the transformed Medicaid program. As a threshold matter, this claim is
legally irrelevant to the coercion analysis. Defendants do not dispute the costs and
burdens forced onto the States, but merely point to the potential for States to receive
collateral benefits. In fact, Defendants have no credible support for their claim of
offsetting savings. They place primary reliance on a report by the President’s own
Council of Economic Advisors (“CEA”), made months before the ACA’s passage. But
the CEA report is rife with error and mostly identifies potential “savings” that would not
accrue to the States’ fiscs at all; rather, the identified beneficiaries are local governments
– and any savings to them are questionable and, if realized, might actually increase
States’ costs. PRSOMF ¶¶ 48-57. Hence, it is no wonder that the federal agencies and
outside organizations that assessed likely projected costs of the ACA did not even cite the
CEA report. Instead, they project significant net costs to the States, as do the sworn
declarations from representatives of Plaintiff States’ Medicaid agencies.
There is no room for reasonable disagreement: the transformed Medicaid regime
far surpasses the point at which persuasion becomes coercion, in violation of the
Constitution. In addition, it violates every restriction on Congress’s spending power.
Finally, neither the ACA’s Medicaid changes nor the Individual Mandate is
severable from the other provisions of the ACA. The unconstitutionality of either
requires that the Act be struck down in its entirety.
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Argument
I. THE INDIVIDUAL MANDATE IS UNCONSTITUTIONAL A. The Commerce Power Has Limits That Congress Must Respect
Congress’s power under the Commerce Clause, even as augmented by the
Necessary and Proper Clause, is not unlimited. It is firmly established that the
Constitution created a federal government of limited, “‘enumerated powers’ ... which
means that ‘[e]very law enacted by Congress must be based on one or more of’ those
powers.” United States v. Comstock, 130 S. Ct. 1949, 1956 (2010) (citations omitted).
As a result, however broad Congress’s enumerated powers may be, they cannot be
interpreted in a manner that would encompass a general police power. Id. at 1964
(confirming that its decision does not “confer[] on Congress a general ‘police power,
which the Founders denied the National Government and reposed in the States.’”)
(quoting United States v. Morrison, 529 U.S. 598, 618 (2000)).
Several equally fundamental rules derive from that most basic premise. First, the
Commerce Clause itself grants a limited power constrained by the very language of that
provision. United States v. Lopez, 514 U.S. 549, 552–553 (1995) (“[t]he Constitution
creates a Federal Government of enumerated powers,” and there are limits that “are
inherent in the very language of the Commerce Clause.”); Gibbons v. Ogden, 22 U.S. (9
Wheat.) 1, 194-95 (1824) (the very existence of an “enumeration presupposes something
not enumerated”) (quoted in Lopez, 514 U.S. at 551).
Second, the Necessary and Proper Clause, providing adjunct or incidental
authority required for “carrying into Execution” Congress’s regulation of interstate
7
commerce, likewise must be limited so that it does not vitiate the intrinsic limits on the
underlying power.
Third, “[t]he commerce power – that is the combination of the Commerce Clause
per se and the Necessary and Proper Clause,” Garcia v. Vanguard Car Rental USA, Inc.,
540 F.3d 1242, 1249 (11th Cir. 2008), cannot be interpreted in a manner that renders
meaningless either the Constitution’s grant of other limited powers to Congress or the
affirmative restrictions it imposes on those powers in general. “It cannot be presumed
that any clause in the constitution is intended to be without effect; and therefore such a
construction is inadmissible, unless the words require it.” Marbury, 5 U.S. at 174.
In light of these fundamental principles, Defendants’ attempts to justify the
Individual Mandate all fail.
B. The Commerce Power Does Not Support the Individual Mandate
Defendants argue that the Individual Mandate falls within the commerce power
because all individuals eventually will consume healthcare and some will be unable to
pay for that care, effectively “shifting” these costs to third parties. Congress, Defendants
claim, may preemptively require insurance to avoid such “cost-shifting.” DMSJ [Doc.
82-1] at 25-27. However, this convoluted reasoning conflates actual commerce with
potential future commerce, and with failures or refusals to engage in present commerce,
ultimately collapsing into the proposition that the absence of engagement in one type of
commerce (purchasing healthcare insurance) can be regulated by Congress because it
may affect another type of commerce (the consumption of healthcare services) and the
economy in general. Defendants’ position is profoundly flawed.
8
1. The Individual Mandate Does Not Regulate the Healthcare Services Market
First, the Individual Mandate does not regulate the only actual commerce
identified in Defendants’ daisy-chain. The purchase of healthcare services is, of course, a
commercial transaction, though it is typically a local and intrastate transaction rather than
an interstate one.2 But the mandate does not regulate the purchase or consumption of
healthcare services. It does not constrain the type of care consumed or require
consumers to pay for such care in any particular manner. Healthcare services still may be
purchased on a pay-as-you-go basis, and often will be so purchased, particularly where
any desired care exceeds the coverage of ACA-approved insurance policies. Thus,
requiring individuals to purchase healthcare insurance does not regulate the consumption
of healthcare services.3
2. The Commerce Power Only Reaches Activity
Second, the Individual Mandate does not regulate any “activities” that constitute
interstate commerce or that “substantially affect interstate commerce.” Gonzales v.
Raich, 545 U.S. 1, 16–17 (2005). Compelling individuals to engage in a particular type
of commerce, in order to create economic activity, is not the regulation of interstate
2 Any regulation of such intrastate transactions thus already is one step removed from the regulation of interstate commerce and could be justified only because it might have an effect on interstate commerce and be necessary and proper to carry into execution the regulation of such interstate commerce. 3 In this connection, Defendants also incorrectly assert that the Individual Mandate may constitutionally be applied to those who now have healthcare insurance – presumably on the assumption that having entered the market for such insurance they may never leave it. There is no authority for such a proposition.
9
commerce. That power presupposes the existence of the commerce being regulated.4
Moreover, as the very enumeration of a power to regulate interstate commerce
“presupposes something not enumerated,” Lopez, 514 U.S. at 551 (quoting Gibbons v.
Ogden, 22 U.S. at 194-195), there must be a category of “non-interstate commerce” – i.e.,
economic activity which truly is local and beyond Congress’s reach. Id. at 557 (citing
NLRB v. Jones & Laughlin Steel Corp., 301 U.S. 1, 37 (1937)). One obvious and
historically grounded aspect of the category of human existence not subject to the
commerce power is simple passivity, or the failure to engage in commercial transactions.
Here, Congress seeks to regulate inactivity, or the absence of interstate commerce, by
forcing commercial transactions on those who elect not to purchase insurance and thus
not to engage in current interstate commerce. Notwithstanding Defendants’ verbal
gymnastics, inactivity or the absence of commerce cannot be conflated with activity and
commerce without rendering the word “commerce” itself meaningless.
4 This is a limit inherent in the text and structure of the Constitution itself. To the Framing generation, “commerce” was essentially “trade.” Samuel Johnson, A Dictionary of the English Language (J.F. Rivington, et al., eds., 6th ed. 1785) (“Intercourse; exchange of one thing for another; interchange of any thing; trade; traffick.”). Accord Noah Webster, An American Dictionary of the English Language (1828) (“an interchange or mutual change of goods, wares, productions, or property of any kind, between nations or individuals, either by barter, or by purchase and sale; trade; traffick.”). Evidence from the drafting of the Constitution, the Federalist Papers, ratification debates and conventions, and early judicial interpretations confirms this understanding. See Randy E. Barnett, The Original Meaning of the Commerce Clause, 68 U. Chi. L. Rev. 101 (2001). Even scholars who have taken a broader view of the commerce power find a touchstone in activity. See, e.g., Grant S. Nelson and Robert J. Pushaw, Jr., Rethinking the Commerce Clause: Applying First Principles to Uphold Federal Commercial Regulations but Preserve State Control over Social Issues, 85 Iowa L. Rev. 1 (1999) (“the voluntary sale or exchange of property or services and all accompanying market-based activities, enterprises, relationships, and interests”). See Gibbons v. Ogden, 22 U.S. at 189–90 (“intercourse”).
10
That limitation on the Commerce Clause is necessarily recognized by the numerous cases
describing the commerce power as applicable to “activities.” As the Eleventh Circuit has
made clear, the commerce power permits Congress to regulate “three categories of
activities.” Garcia, 540 F.3d at 1249 (emphasis added). These categories include: (1)
“use of the ‘channels’ of interstate commerce;” (2) using the actual “instrumentalities” of
interstate commerce; and (3) “purely intrastate activities when they ‘substantially affect’
or have a ‘substantial relation to’ interstate commerce.” Id. at 1249-1250, citing Raich,
545 U.S. at 25, and Lopez, 514 U.S. at 558, among other authorities.
Nor does the Individual Mandate regulate a commercial or economic “activity”
that substantially affects interstate commerce. While Congress also can regulate certain
purely intrastate and local commercial activities under the Necessary and Proper Clause,
it still must direct such a regulation to an existing commercial activity. Garcia, 540 F.3d
at 1250 (“intrastate activities”). Defendants have not identified a single case (with the
exception of the wrongly decided Thomas More Law Center v. Obama, 2010 WL
3952805 (E.D. Mich. Oct. 7, 2010)) even suggesting that the commerce power reaches
beyond the regulation of actual economic activity.
3. Inactivity Cannot be Redefined as “Economic Activity”
Defendants engage in Orwellian efforts to redefine the inactivity of not having
healthcare insurance as an affirmative economic activity of “deciding” not to buy
insurance, or deciding now how to pay (or not to pay) for potential future economic
activity in the form of obtaining medical services. These efforts are insupportable by
language, law, reason, and precedent. To be “active” in a market, a person must be
11
selling, buying, producing, transporting, using, or possessing a good or service available
in that market. The same is true of both the market for healthcare services and the market
for healthcare insurance. There is nothing “unique” about those markets.5
If the “decision” not to engage in commerce is an economic activity that may be
regulated either as interstate commerce itself, or as having a substantial effect on
interstate commerce, then the very notion of “commerce” is empty of meaning and
encompasses everything. Under Defendants’ theory, all decisions in life can be recast as
decisions to forego some alternative economic activities, and therefore fall under
Congress’s reach. The decision to sleep becomes a decision not to work, and hence an
economic activity. The decision to rest on the weekend becomes a decision not to engage
in commercial behavior. The decision to go to high school or college becomes a decision
to postpone entry into the labor market. As the Lopez Court correctly explained, such
tortured reasoning “lacks any real limits because, depending on the level of generality,
any activity can be looked upon as commercial.” Lopez, 541 U.S. at 565.
It is no answer to state the obvious point – and one of which the Supreme Court
surely has been aware all along in limiting the commerce power to activity – that the
absence of consumers, i.e., their inactivity, can have secondary effects on a market. The
lack of demand for, e.g., orange juice can impact citrus growers, processors, marketers,
5 As noted below, one of Defendants’ own experts indicates that these two “markets” are, in fact, quite separate and distinct. See infra at 22-23. Defendants have not explained how the alleged characteristics of the market for medical services render the market for healthcare insurance different from any other insurance market involving the management of widely-shared significant risks, such as the markets for life insurance or disability insurance.
12
and sellers, on the supply side; and it can affect prices paid by consumers, on the demand
side (depending on how the aggregate supply is adjusted). But these are effects on
persons or businesses who are voluntarily active in the market. The same can be said of
virtually any conceivable market. Inactivity of itself is neither “economic” nor
“financial,” despite Defendants’ claims to the contrary. DMSJ at 27.
Similarly, as with healthcare, the timing of individual entries (and exits) in
markets generally, including markets for necessities, is unpredictable and can involve
extensions of credit and substantial costs which many consumers, at length, may be
unable to pay. Their defaults result in the same “cost-shifting” that Defendants wrongly
contend applies solely to healthcare. But cost-shifting takes place among active market
participants, as losses caused by defaulting consumers are either absorbed by suppliers or
passed along to other participants – all of whom are voluntarily active in the market.6
Moreover, Defendants’ absurd claim that anyone without healthcare insurance is
“engaged in economic activity to an even greater extent than the plaintiffs in Wickard or
Raich,” DMSJ at 29, not only defies language and logic, but also ignores the genuine
activities regulated in those and other cases. As the Court already has noted with respect
to Wickard v. Filburn, 317 U.S. 111 (1942) and Heart of Atlanta Motel v. United States,
379 U.S. 241 (1964), Congress merely was regulating the economic and commercial
activities in which the complainant parties had chosen to engage. Mem. Op. at 62-63. In
6 In this regard, it is worth emphasizing that cost-shifting is ubiquitous in all segments of the modern economy, because of the widespread availability of credit and the increasing rarity of cash payment for goods or services upon delivery. The consequences for the economy in such cases may differ in degree, but not in kind, from those attending the healthcare market.
13
Wickard and Raich, Congress regulated commodities indisputably within its reach, and
the parties could have avoided federal regulation through the simple expedient of
choosing not to grow, consume, or use the relevant substances.
The same is true of every appeals court case Defendants cite. See United States v.
Ambert, 561 F.3d 1202, 1211 (11th Cir. 2009) (regulating sex offenders when they
“travel[] in interstate or foreign commerce”); United States v. Gould, 568 F.3d 459, 470
(4th Cir. 2009) (same); United States v. Olin Corp., 107 F.3d 1506, 1510 (11th Cir. 1997)
(regulating “the disposal of hazardous waste”); United States v. Maxwell, 446 F.3d 1210,
1216–17 (11th Cir. 2006) (regulating “the receipt, distribution, sale, production,
possession, solicitation and advertisement of child pornography”); Alabama-Tombigbee
Rivers Coal. v. Kempthorne, 477 F.3d 1250, 1272, 1277 (11th Cir. 2007) (regulating the
“tak[ing]” of endangered fish); United States v. Belfast, 611 F.3d 783, 793, 814 (11th Cir.
2010) (punishing violence and use of a firearm); Garcia, 540 F.3d at 1252 (regulating
“the commercial leasing of cars”); United States v. Williams, 121 F.3d 615, 618–19 (11th
Cir. 1997) (regulating the obligation to “pay money” in the form of a child support award
which “crossed state lines.”). In each case, the courts upheld the regulation of an activity.
4. Defendants Can Identify No Meaningful Limiting Principle
Defendants’ argument leads inexorably to an infinite commerce power and leaves
this and other courts with no coherent or judicially manageable doctrine to limit Congress
to its enumerated powers, or to preserve some non-redundant purpose for many other
parts of the Constitution. If the Commerce Clause is as broad as Defendants claim, it is
difficult to imagine any requirement or regulation that would be beyond it. Indeed, under
14
Defendants’ theory, it is inexplicable why the Constitution’s Framers found it necessary
to enumerate so many other powers to be vested in Congress – for example, the powers to
establish uniform laws on bankruptcies, to coin and regulate the value of money, to
punish counterfeiting, to establish post offices and post roads, to provide for patents and
copyrights, and to define and punish piracy. U.S. Const. Art. I, § 8, cls. 2, 3, 4, 5, 6, 7, 9.
The exercise of these powers (and many more) certainly falls well within the
expansive commerce power Defendants posit, and therefore would be redundant or
meaningless in light of so broad a commerce power. Such an interpretation of the
Constitution is impermissible. See Marbury, 5 U.S. at 174 (“[i]t cannot be presumed that
any clause in the constitution is intended to be without effect; and therefore such a
construction is inadmissible, unless the words require it.”).7
5. Limiting the Commerce Power to Commercial Activities Is a Necessary Constraint on Congress
Defendants’ entire theory of
the case – that individuals who are absent from a market can be regulated by Congress
even though they have not voluntarily engaged in any commercial activity – admits of no
limiting principle, and Defendants have not identified any.
Far from “empty formalism,” DMSJ at 16, limiting the commerce power to the
regulation of activities is necessary to the judicial enforcement of any other limits on
7 Defendants suggest that the Bill of Rights would remain as some limit on congressional power. DMSJ at 23. This, however, is not the Constitution’s design. Congress’s authority is limited both by the limited and enumerated nature of its powers, see, e.g., Lopez, 514 U.S. at 553 (noting that “limitations on the commerce power are inherent in the very language of the Commerce Clause.”), and by the Bill of Rights. Elimination of the constraints inherent in Article I cannot be justified by reference to the continuing existence of those contained in the Bill of Rights. Moreover, Defendants’ position would also render any analysis of “rationality” under the Due Process Clause superfluous.
15
congressional power.8
Like the commercial/non-commercial limiting doctrine set out in Lopez, the
activity/inactivity line has a long history of practical adherence and recognition. The
novelty of Congress’s current attempt to escape this prior limit – and hence the dearth of
case authority enforcing that limit – confirms its existence and vitality.
It is this most fundamental constraint which keeps Congress’s
broad authority to regulate interstate commerce from becoming an impermissible general
federal police power, and which provides a clear and judicially enforceable limiting
doctrine. Cf. Comstock, 130 S. Ct. at 1964 (“‘Nor need we fear that our holding today
confers on Congress a general ‘police power, which the Founders denied the National
Government and reposed in the States.’”) (quoting United States v. Morrison, 529 U.S.
598, 618 (2000)).
6. Only a Forbidden Police Power Could Support the Mandate
Only a forbidden “police power that would authorize enactment of every type of
legislation,” Lopez, 514 U.S. at 566, could support the Individual Mandate.9
8 Moreover, as the Supreme Court explained in New York v. United States, 505 U.S. 144, 187 (1992), “[m]uch of the Constitution is concerned with setting forth the form of our government, and the courts have traditionally invalidated measures deviating from that form. The result may appear ‘formalistic’ in a given case to partisans of the measure at issue, because such measures are typically the product of the era’s perceived necessity. But the Constitution protects us from our own best intentions.”
Defendants
have no answer to this point. Indeed, their references to other instances in which
Congress has imposed “mandates” are as inapposite as the authorities they cite, because
9 The ability to regulate individuals based only on their presence in a jurisdiction is, of course, the defining characteristic of a “police power.” Cf. Jacobson v. Massachusetts, 197 U.S. 11, 25 (1905) (upholding State’s right to require an individual’s smallpox vaccination simply because he was present in the State).
16
in those cases Congress relied on other enumerated powers, not the Commerce Clause.
DMSJ at 32. In each such case, the mandate was grounded in a grant of authority that
necessarily included the power to command the service of individuals as a matter of law,
logic, and longstanding practice based on the most fundamental attributes of citizenship.
See, e.g., Selective Draft Law Cases, 245 U.S. 366, 378–79 (1918) (authority to compel
service recognized as inherent in the very notion of citizenship and the power to raise and
support armies); In re: Heritage Propane, 2007 U.S. Dist LEXIS 88933, *4, *7 n.3 (E.D.
Tenn. Feb. 6, 2007) (“The right to a jury trial is a fundamental part of the American
judicial system,” and as a result, “[t]he jury is as much an institution of self government
as is the election of public officials. Jury service on the part of citizens of the United
States thus has become one of the most important and basic rights and obligations of
citizenship.”).10
The Commerce Clause, by contrast, suggests no such power to dragoon the
citizenry into the service of Congress’s national policy goals.
11
10 In Re Quarles, 158 U.S. 532 (1895), cited by Defendants, is inapposite. The case stands only for the proposition that the federal government may provide, through a prohibition on criminal conspiracies, for the protection of witnesses and informants. It does not establish any legally enforceable requirement that a citizen must do anything, much less that the commerce power would allow Congress to impose such a requirement. Id. at 535 (analogizing citizen’s duty to come forward with evidence of a crime to duty to act as part of the posse comitatus). In any case, service in the “posse comitatus” also was a recognized incident of citizenship at the time the Constitution was ratified. Mejia v. City of New York, 119 F. Supp. 3d 232, 262 & n.33 (E.D.N.Y 2000). The existence of such authority says nothing whatsoever about the proper scope of the commerce power.
Certainly, enactment of
11 Indeed, Defendants are oblivious to the fact that their argument would fundamentally redefine the nature of federal citizenship, altering the relationship between the federal government and the People and violating a number of constitutional provisions. For an argument that this would violate the Tenth Amendment, see Randy E. Barnett,
17
the Comprehensive Environmental Response, Compensation, and Liability Act
(“CERCLA” or “Superfund”) provides no such precedent. Contrary to Defendants’
claims, DMSJ at 30-31, CERCLA only imposes a “mandate” based on various activities,
including ownership and possession, related to the disposition of hazardous materials. 42
U.S.C. § 9607(a). The fact that a particular owner may not have caused the relevant
environmental damage is irrelevant to questions of liability, but ownership or possession
of the source of the damage is relevant – which is why an entire industry providing
“environmental audits” has blossomed since Superfund’s passage in 1980. Land titles
now carry with them obligations that, once title is taken, cannot necessarily be discharged
by sale or other disposition of the property. These obligations, however, can be avoided
by not becoming involved in the disposition of hazardous wastes or by not taking title to
property where such wastes may be present.12
Finally, the constitutional implications of Defendants’ argument are both
profound and staggering. Defendants suggest that every individual is a “market
participant” because every individual either has used or will use healthcare services at
Commandeering the People: Why the Individual Health Insurance Mandate is Unconstitutional, NYU J.L. & Liberty (forthcoming), available at http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1680392. 12 Eminent domain, also cited by Defendants, likewise is inapposite. Although euphemistically described as a “forced sale” (a term not embraced by the Court in Luxton v. North River Bridge Co., 153 U.S. 525 (1894)), the exercise of the power of eminent domain in fact involves the taking of private property for public purposes. Id. at 529. It is the land, and not the landowner, that is subject to condemnation and the object of governmental power. See, e.g., Kelo v. City of New London, 545 U.S. 469, 483–84 (2005). Similarly, each of the various insurance “mandates” cited by Defendants also is contingent on, and regulates, specific economic activities. DMSJ 30 n.9.
18
some point in time, making everyone subject to regulation under the Commerce Clause.
The foundation of this position, of course, is that no one can avoid this particular market
and, once in the market, no one may withdraw. Moreover, while permanently a part of
this eternal market, everyone would be subject to regulation, and that regulation would
not be limited to an individual insurance mandate. Like the businesses regulated by the
Fair Labor Standards Act, individuals could be required to provide benefits and services
as Congress deemed appropriate. No one, from birth to death, could avoid being
regulated. Like the Individual Mandate itself, such absolute federal power over any
aspect of life is unprecedented and insupportable based on the text, history and consistent
interpretation of the Constitution.
C. The Mandate Cannot Be Saved by the Necessary and Proper Clause
1. The Individual Mandate Fails under the Comstock Factors As Plaintiffs have demonstrated in Pl.Opp.MTD [Doc. 68] at 33-36 and PMSJ
[Doc. 80-1] at 17-23, the Individual Mandate plainly fails every consideration identified
by the Supreme Court in Comstock, its latest opinion dealing with the Necessary and
Proper Clause (albeit not in the context of the commerce power). The Individual
Mandate is by no means a “modest” or “narrow” provision; it is not supported by any
long “history of involvement” of Congress in compelling the purchase of insurance; it is
not the “means for implementing a constitutional grant of legislative authority,” as shown
below; and it does not “properly account[] for State interests,” as shown above. See
Comstock, 130 S. Ct. at 1962. Instead, the mandate represents an unprecedented
intrusion of federal governmental power into Americans’ lives, and in effect creates a
19
general federal police power that is reserved to the States under the Constitution. As a
consequence, the Necessary and Proper Clause cannot rescue the mandate.
2. The Mandate Is Not “Essential” to a Larger and Legitimate Regulatory Scheme
The Individual Mandate also cannot be sustained as an “essential” part of some
larger and legitimate regulatory scheme. Defendants’ reliance on Raich in this respect is
particularly misplaced. The Raich Court upheld Congress’s regulation of purely
intrastate cultivation, possession, and use of marijuana as being “essential” to its larger
scheme to regulate dangerous drugs, entirely eliminating certain of these from the
interstate market through the Controlled Substances Act (“CSA”). It did so because these
intrastate “activities” were the same as those “quintessentially economic” activities
regulated on the interstate level by the CSA, reasoning that “prohibiting the intrastate
possession or manufacture of an article of commerce is a rational (and commonly
utilized) means of regulating commerce in that product.” Raich, 545 U.S. at 24-26
(emphasis added). Failing to regulate “such a significant segment of the total market
would undermine the orderly enforcement of the entire regulatory scheme.” Id. at 28.
The Individual Mandate does not regulate any activity, economic or otherwise,
which could undermine enforcement of another regulatory scheme. Nor does the
mandate serve to implement an otherwise legitimate regulation of interstate commerce, as
did the recordkeeping requirements upheld as necessary and proper in United States v.
Darby, 312 U.S. 100, 124–125 (1941). It is, in fact, a measure directly designed to
achieve Congress’s ultimate end, viz., universal healthcare insurance coverage.
Defendants’ assertions that the Individual Mandate was meant to implement
20
ancillary provisions of the ACA governing the sale and content of healthcare insurance
policies, DMSJ 19–20, are insupportable. Those provisions, requiring insurance
companies to cover preexisting conditions, regulating premiums, and eliminating lifetime
benefit caps, are actually “essential” to implementing the mandate. They make it
possible for those with preexisting or chronic conditions to secure and maintain the
healthcare insurance coverage the Individual Mandate requires.
The ACA’s structure, text, and legislative history make this plain. The only
congressional findings in Title I of the ACA relate to the “individual responsibility”
provision, and those findings state that the provision’s primary purpose is to “achieve
near-universal coverage.” ACA § 1501(a)(2)(D). Cf. Remarks by the President at
Signing of the Health Insurance Reform Bill, http://www.whitehouse.gov/the-press-
office/remarks-president-and-vice-president-signing-health-insurance-reform-bill, March
23, 2010 (“And we have now just enshrined, as soon as I sign this bill, the core principle
that everybody should have some basic security when it comes to their health care.”).
The other findings, citing other provisions of the Act, are subsidiary to this goal. Indeed,
it was the Individual Mandate that Congress identified as “essential” to its legislative
purpose, not the two lesser provisions – “guaranteed issue” and “community rating” –
that Defendants now assert the Individual Mandate serves to implement. DMSJ 20–21.
This reflects a reality that Defendants do not seriously challenge. With or without
the Individual Mandate, “guaranteed issue” and “community rating” still could be
21
implemented in some fashion as effective commercial regulations.13 Defendants do not
even allege that either provision would operate less effectively or be more difficult to
administer in the absence of a mandate, but merely that the lack of a mandate would
“amplify incentives” for individuals to engage in cost-shifting. DMSJ 20–21.14
Upholding the Individual Mandate as “essential” to the ACA’s insurance
regulations would license Congress to create and expand its own regulatory power
through the simple expedient of legislating in such a manner as to create its own
“necessity,” as a means to obtain sufficient power to achieve its true object. This is the
very antithesis of a limiting principle: congressional authority would be restrained only
where Congress does not act in the context of a broad regulatory scheme. Under that
approach, where Congress does enact a broad regulatory scheme, even one whose goals
However, this is a direct consequence not of anyone’s failure to have insurance, but of
Congress’s own legislative actions. Absent the mandate, the insurance provisions would
not achieve Congress’s actual goal of guaranteeing universal healthcare coverage. But
that ultimate political goal, however laudatory, is not a legitimate end “within the scope
of the constitution” to which the Necessary and Proper Clause may be applied.
Comstock, 130 S. Ct. at 1956 (quoting McCulloch, 17 U.S. at 421).
13 This stands in marked contrast, for example, to the situation in Raich, where the central provision of the Controlled Substances Act – viz., the prohibition of the production, transport, distribution, etc., of dangerous drugs – would have been rendered wholly inoperative in many instances without the ability to reach intrastate activity. 14 This point is indistinguishable from the argument rejected in Lopez that Congress may “regulate any activity that it found was related to the economic productivity of individual citizens.” 514 U.S. at 564. Potentially any action or inaction may affect individuals’ incentives; were that alone sufficient to support federal regulation, it would be “difficult to perceive any limitation on federal power.” Id.
22
are beyond the reach of its enumerated powers, it would face no limits.
In fact, the Individual Mandate is precisely the type of “evasive legislation” –
provisions attached to other legislation (however broad or narrow) as a means of
regulating beyond what the commerce power otherwise would support, see Raich, 545
U.S. at 46-47 (O’Connor J., dissenting) – which the Raich Court acknowledged to be a
potential danger, but which it did not find to be present in that case. See id. at 25 n.34
(“there is no suggestion that the CSA constitutes the type of ‘evasive’ legislation the
dissent fears, nor could such an argument plausibly be made.”). The mandate cannot be
sustained as “necessary” or “essential” to the ACA’s insurance reforms.
3. The Mandate Is Too Remote from the Insurance Regulations It Supposedly Supports
Even if the mandate were designed to support the ACA’s insurance provisions, it
would fail. Defendants rest their “economic activity” theory on presumed participation in
the market for healthcare services, not the market for healthcare insurance that Congress
purported to regulate with the Individual Mandate. However, as explained by one of
Defendants’ own authorities, “[a] common feature of several myths [about healthcare in
America] is the conflation of health, health care and health insurance. The three are
surely connected, but they are not the same.” Katherine Baicker & Amitabh Chandra,
Myths and Misconceptions about U.S. Health Insurance, 27 Health Affairs w533 (2008)
(DMSJ, Ex. 6). Thus, “[u]ninsured Americans who are sick pose a very different set of
problems. They need health care, not health insurance. Insurance is about reducing
uncertainty in spending. It is impossible to ‘insure’ against an adverse event that has
already happened.” Id. at w534.
23
Even if every American were a constant “participant” in the market for healthcare
services, and surely they are not, that would not make them participants in the healthcare
insurance market. Indeed, Congress itself sought to justify the Individual Mandate as a
means of bringing individuals into the latter market, not to regulate their consumption of
services in the former market. See ACA §§ 1501(a)(2)(G) (“[b]y significantly increasing
health insurance coverage, the requirement, together with the other provisions of this Act,
will minimize this adverse selection and broaden the health insurance risk pool to include
healthy individuals”), 1501(a)(2)(H) (“[b]y significantly increasing health insurance
coverage and the size of purchasing pools ... the requirement, together with the other
provisions of the Act, will significantly reduce administrative costs and lower health
insurance premiums”).
Thus, any market participation by those subject to the Individual Mandate is at
least once removed from Congress’s purported regulatory target, the healthcare insurance
market. In fact, the mandate is yet several more steps removed from the insurance
market regulations which it supposedly supports. Defendants and Congress claim that
the mandate will reduce the dangers of “market timing” and “cost-shifting,” which are
exacerbated by the ACA’s new rules on preexisting conditions and lifetime benefit caps.
This claim, however, is based upon exactly the type of attenuated chain of effects that
was rejected by the Lopez Court. Lopez, 514 U.S. at 567. See also Comstock, 130 U.S. at
1963 (links between challenged statute “and an enumerated power are not too
attenuated.”). Here, the mandate’s support for the ACA’s insurance regulations
necessarily posits that: (1) everyone will consume healthcare services; (2) some persons
24
who can afford healthcare insurance will not buy it, to save money; (3) some significant
percentage of these persons, when they do fall ill, will not pay for the healthcare services
they consume; (4) providers will seek to shift these costs to insurers, and by extension to
the healthcare insurance market in general, because the ACA requires insurers to take all
comers; (5) requiring all individuals to have healthcare insurance will avoid such cost-
shifting sufficiently to reduce premiums. See DMSJ at 19-25. This is the sort of
reasoning that the Lopez Court rejected, and the same result must obtain here.15
D. That No Previous Congress Believed the Commerce Power To Support Enactment of Individual Mandates Negates Such a Power’s Existence
For more than two hundred years, Congress has understood and accepted the
fundamental limits on the commerce power. Before passage of the ACA, no Congress
ever had required individual Americans to buy a particular good or service as a supposed
regulation of “commerce.”16
15 Given the integrated and interrelated nature of the modern market economy, both at the national and even global levels, under the Defendants’ logic it would be possible to conflate all manner of markets for the purpose of determining whether an activity being regulated is reachable under the commerce power. This approach, which is insusceptible of any meaningful limiting principle, would contravene the teaching of Lopez and Raich, in which the Court recognized that intrastate activities only can be regulated if they are not too remote from the interstate activities at issue.
Although a statute’s novelty does not establish its
unconstitutionality, the Court has made clear that the “‘absence of power’ to do
something c[an] be inferred because Congress ha[s] never made an attempt to exercise
16 This most certainly was not the case in Wickard v. Filburn, as Defendants incorrectly suggest. DMSJ at 29. Filburn only was subject to congressional regulation because he was voluntarily engaged in the business of wheat farming. He could have avoided regulation by cultivating some other, unregulated crop to meet his needs. The Individual Mandate offers no such choice.
25
that power before.” Mem Op. at 64-65 (citing Printz v. United States, 521 U.S. 898, 905,
907-908, 918 (1997)).17
The power to require directly that all Americans obtain a particular good or
service, including insurance, might be attractive from Congress’s perspective. Yet, for
generations, in seeking to achieve various political, economic, and social goals through
the commerce power, Congress instead has taken care to restrict itself to utilizing indirect
regulations to achieve its ends. It purposely has linked regulations to economic activities
in or affecting interstate commerce, even though its broader goals often could have been
achieved more directly through a mandate on businesses or individuals.
The Printz Court’s statement that if “earlier Congresses avoided
use of this highly attractive power, we would have reason to believe that the power was
thought not to exist,” Printz, 521 U.S. at 905, is particularly instructive.
18
17 According to the Congressional Budget Office (“CBO”), a congressional agency with “the primary duty and function” of advising Congress on “bills authorizing or providing new budget authority,” 2 U.S.C. § 602(a), an individual healthcare insurance mandate is unprecedented in two respects: “First, it would impose a duty on individuals as members of society. Second, it would require people to purchase a specific service that would be heavily regulated by the federal government.” Robert Hartman & Paul Van de Water, The Budgetary Treatment of an Individual Mandate to Buy Health Insurance, CBO Memo. Aug. 1994, at 1. Similarly, the Congressional Research Service (“CRS”), a congressional agency charged with “determining the advisability of enacting [legislative] proposals,” 2 U.S.C. § 166(d)(1), found it “a novel issue whether Congress may use [the Commerce Clause] to require an individual to purchase a good or service.” Jennifer Staman & Cynthia Brougher, Requiring Individuals To Obtain Health Insurance: A Constitutional Analysis, CRS Report No. R40725, July 2009, at 3. See id. at 6 (distinguishing a mandate from Congress’s usual use of its commerce power to regulate those “who voluntarily take part in some type of economic activity”) (emphasis added).
18 See, e.g., 29 U.S.C. § 212(a) (prohibition on child labor implemented as limitation on shipment of goods in interstate commerce); 15 U.S.C. § 78i(a) (prohibiting “manipulation of security prices” when accomplished “by the use of the mails or any means or instrumentality of interstate commerce” or through a national securities exchange); 21 U.S.C. § 62 (making it unlawful “to ship or deliver for shipment in interstate or foreign
26
There is no better example of this practice – manifesting Congress’s respect for
the commerce power’s limitations – than the National Flood Insurance Program
(“NFIP”), which Defendants incorrectly cite as an example of another individual mandate
requiring persons to obtain insurance. DMSJ at 30. According to the United States
Geological Survey, “[d]uring the 20th century, floods were the number-one natural
disaster in the United States in terms of number of lives lost and property damage. They
can occur at any time of the year, in any part of the country, and at any time of the day or
night.” Charles A. Perry, Significant Floods in the United States During the 20th
Century – USGS Measures a Century of Floods, Mar. 2000,
http://ks.water.usgs.gov/pubs/fact-sheets/fs.024-00.html (last visited Nov. 23, 2010).
Economic damage from flooding runs well into the billions of dollars annually. National
Weather Service, Flood Losses: Compilation of Flood Loss Statistics, http://www.
nws.noaa.gov/hic/flood_stats/Flood_loss_time_series.shtml (last visited Nov. 23, 2010).
Congress has acted to ameliorate these losses through the NFIP, established under
the National Flood Insurance Act of 1968, as amended, 42 U.S.C. § 4001, et seq. As
Defendants state, the NFIP includes a “mandate” that certain individuals have flood
insurance. However, despite the severe and national scope of the problem, Congress did
not impose an individual insurance mandate that all Americans, or all homeowners, or
even anyone living in a flood plain must obey on pain of penalty. Acting within its
constitutional parameters, Congress required flood insurance only as a condition of commerce” any “filled milk”); 21 U.S.C. § 331(a) (central provision of the Food, Drug and Cosmetic Act prohibiting the “introduction or delivery for introduction into interstate commerce of any food, drug, device, tobacco product, or cosmetic that is adulterated or misbranded”).
27
securing and maintaining a mortgage from a federally-regulated financial institution. 42
U.S.C. §4012a(a)(b) & (e). The requirement does not apply to property owners who do
not have such mortgages or to anyone else who lives under threat of flooding.
To the extent that Congress wanted to keep those without flood insurance from
imposing costs on others, a far more direct regulation would have been simply to require
all individuals living in a flood plane to have insurance. But the 90th Congress took the
indirect and constitutionally-permissible route, because it understood that the commerce
power permits regulation of interstate commerce – including mortgage lending – but not
of individual Americans, even if they live in a flood plain. As the Printz Court stated,
“two centuries of apparent congressional avoidance of the practice ... tends to negate the
existence of the congressional power asserted here.” Printz, 521 U.S. at 918.
II. THE ACA’S MEDICAID TRANSFORMATION IS UNCONSTITUTIONAL
Defendants’ request for summary judgment on Count Four of the Amended
Complaint likewise must be denied. Defendants fail to controvert any of the key facts
upon which Count Four is based. Indeed, Defendants do not contest:
• that the Medicaid program is long-established and critically relied upon by tens of
millions of poor and needy residents in the States;
• that the ACA fundamentally transforms Medicaid, and the States’ partnership role
and financial obligations in the program, in precisely the ways that Plaintiffs
contend;
• that Congress, in creating the ACA’s very structure, presupposes and depends on
the States’ inability to walk away from Medicaid;
28
• that no transitional mechanism exists under law to facilitate an orderly withdrawal
from Medicaid by a State so as to avoid jeopardizing the lives and welfare of
millions of its poorest and neediest residents; and
• that States’ withdrawal from Medicaid would mean the loss of funding from the
Nation’s single largest grant program – a whopping $251 billion per year
comprising 40 percent of all federal outlays to States and averaging 20 percent of
States’ budgets – while State citizens still would be required through payment of
taxes to fund Medicaid programs of participating States.
Instead of meeting the thrust of Plaintiffs’ position, Defendants point to how
much more the federal government will be spending under the ACA. However, this
response is legally irrelevant to whether the Act unlawfully coerces and commandeers the
States. Congress simply does not possess an untethered ability to transform Medicaid in
any manner that it wishes. If anything, enhanced federal funding underscores the ever-
increasing power that the ACA exerts over the States: the more the federal government
spends, the more it taxes resources away from residents and businesses of the States; the
greater the diversion of local resources to Washington, D.C., the greater the States’ need
for subsidies from the federal government; and the greater the States’ need for such
subsidies, the stronger the federal government’s position to dictate coercive and arbitrary
conditions which the States must accept.19
19 As this Court noted, “if the state plaintiffs make the decision to opt out of Medicaid, federal funds taken from their citizens via taxation that used to flow back into the states from Washington, D.C., would instead be diverted to states that have agreed to continue participating in the program.” Mem. Op. at 56.
29
Defendants then fantastically assert that the Act will save the States money.
Defendants rely primarily on a pre-ACA report of the President’s Council of Economic
Advisers (“‘CEA”). However, as Plaintiffs’ responsive Declarations show, that report is
based on demonstrably invalid assumptions, which probably explains why none of the
federal agencies tasked with assessing the Act’s impact – including the CBO, which
estimated the net costs to the States to be in excess of $20 billion – even cited it. See
PRSOMF ¶ 48. Significantly, the CEA report, like Defendants themselves, completely
ignores the Act’s new requirement that the States (but not the federal government) be
responsible for the provision of healthcare services, an obligation that could lead to
tremendous costs for the States, particularly in light of projected shortages of providers
for Medicaid recipients. It also ignores ACA provisions that prohibit States from
tightening eligibility requirements – a typical but important way for States to control
costs – and, for the first time, prevents them from reducing huge optional outlays
(comprising 60 percent of States’ Medicaid spending). See Anna Sommers, Medicaid
Enrollment and Spending by “Mandatory” and “Optional” Eligibility and Benefit
Categories, Kaiser Comm’n on Medicaid & the Uninsured, June 2005, at 11.
Moreover, the entire question of whether the States’ costs might to some extent be
offset by collateral savings is legally irrelevant: regardless, the ACA represents a
substantial departure from the Medicaid partnership between the federal government and
the States, and imposes heavy new burdens that the States cannot avoid.
30
Once the preposterous assertion that the ACA will save the States money is swept
aside, Defendants are left with rearguing the justiciability of Plaintiffs’ claim, an issue
already resolved against them by this Court.
Finally, Defendants fail to address that the ACA’s overhaul of Medicaid violates
every restriction on Congress’s spending power under Article I of the Constitution.
A. Defendants Cannot Dispute the ACA’s Significant Alterations to Medicaid
As the Supreme Court noted in Harris v. McRae, 448 U.S. 297, 301, 308 (1980),
“[t]he Medicaid program was created … for the purpose of providing federal financial
assistance to States that choose to reimburse certain costs of medical treatment for needy
persons.” (Emphasis added.)
The ACA undoes every critical characteristic of the Medicaid partnership between
the States and the federal government. Medicaid was enacted to address healthcare needs
of the poor and needy, but the ACA expands eligibility to all persons whose income is up
to 38 percent above the federal poverty line. Medicaid was limited to reimbursing needy
persons’ healthcare expenses, but the Act now requires the States (but not the federal
government) to provide medical care. ACA § 2304.20
20 The Harris Court, as if anticipating the ACA, warned of federal overreaching of the Medicaid partnership: “Title XIX was designed as a cooperative program of shared financial responsibility, not as a device for the Federal Government to compel a State to provide services that Congress itself is unwilling to fund.” 448 U.S. at 309 (emphasis added).
These undeniable changes go far
beyond the original Medicaid partnership. In effect, they constitute a new Medicaid
regime, imposed in top-down fashion – the antithesis of partnership.
31
It is no answer to say that the States, in entering into their pre-ACA Medicaid
programs, agreed that the federal government could amend the programs. The federal-
state Medicaid partnership agreement did not afford plenary power to the federal
government to make any Medicaid revision that it wished irrespective of the States’
expectations, or to bully the States with threats to remove them from the program for
failing to accept transformative and harmful new conditions. Prior amendments to the
States’ Medicaid programs involved comparatively modest refinements of eligibility
criteria (or optional revisions – again, 60 percent of Medicaid spending being optional)
for the benefit of the poor, young, aged, and infirm populations. Judicial decisions cited
by Defendants (DMSJ at 48) have upheld such amendments as they comport with the
basic nature of the partnership that States voluntarily entered. The States could foresee
these amendments, which were consistent with the well-settled Spending Clause
requirement that Congress must not condition funding to the States on ambiguous terms.
See South Dakota v. Dole, 483 U.S. 203, 207-08 (1987). But those earlier changes are a
far cry from the ACA’s blanket departure from needy eligibility categories and its
substitution of broad income-based eligibility 38 percent above the federal poverty line.
Moreover, the States could not have foreseen that Congress would impose on
them the burden of being responsible for providing healthcare services themselves rather
than merely reimbursing the healthcare costs of the needy. This change exposes the
States to massive costs, burdens, and potential liabilities to which they never agreed, and
which Congress has refused to share. As Plaintiffs have shown, PMSJ [Doc. 80-1] at 41
n.41 & 42 n.42, a serious shortage of Medicaid providers is projected. This shortage, on
32
top of ACA’s imposed new burden that that the States be responsible for the provision of
services, will put the States in a terrible dilemma: either increase their Medicaid
expenditures drastically to attract sufficient numbers of providers, or face potentially
catastrophic liabilities for widespread failures to furnish needed healthcare services in
timely fashion. While this ACA imposition alone could bankrupt the States, none of the
government agencies and outside organizations assessing the ACA’s overall costs has, to
Plaintiffs’ knowledge, even ventured to assign a dollar figure for this burden. So glaring
an omission surely is not the result of the cost being trivially small; if anything, the
omission reflects that the cost is so gargantuan as to defy estimation – which probably
explains why the federal government has refused to be co-responsible for this burden.
In addition, while the Medicaid partnership afforded States wide discretion to
control various aspects of their programs, the ACA removes this and imposes
maintenance-of-effort requirements that punish States by locking in their previously-
optional higher spending levels and freezing those levels in place for a prescribed period.
See Sommers, supra (more than 60 percent of Medicaid spending is optional). As with
the other changes imposed by the ACA, this elimination of discretion – an important
factor to controlling program costs – was not reasonably foreseeable by the States.
In effect, Congress has scuttled the existing Medicaid program in favor of a new
program that is vastly different and specially designed to facilitate the ACA’s goal of
near-universal coverage – a goal wholly distinct from the previous Medicaid objective of
helping the needy. Thus, the ACA greatly widens the Medicaid “door” so that a much-
enlarged population can pass through it to comply with the Individual Mandate.
33
The ACA makes no provision for States to continue their participation in
Medicaid under its pre-ACA terms. Nor does the ACA make any provision for States
either to exit Medicaid or to effect a safe transition from Medicaid that would protect
their needy residents. Thus, Congress seeks to use its funding hold over the existing
Medicaid partnership to force the States to accept the new Medicaid regime and its
obligations and costs. This Hobson’s choice is an abuse of Congress’s spending power.
B. The ACA’s Transformation of Medicaid Harms the Plaintiff States’ Budgets and Sovereignty
Defendants argue that the ACA is not coercive because the increased State
spending required by the ACA will be small compared to federal spending levels and
because the ACA is broadly beneficial. Mem. at 39. Defendants understate the
magnitude of the States’ Medicaid obligations under the ACA, which they modestly
calculate to be 1.4 percent over existing baseline projections, while wholly ignoring (1)
the well-documented fiscal emergency in States arising from those same baseline
projections of spiraling State Medicaid obligations that threaten their fiscal viability; (2)
the dangerous expansion of State obligations that requires States to be responsible for the
provision of healthcare services, with a virtually certain massive increase in liability; and
(3) the elimination of States’ flexibility under Medicaid to control their costs. In sum, the
ACA’s transformation of Medicaid stands to run State budgets off the proverbial cliff.
1. Plaintiffs’ Coercion Claim Is Not Undermined By Increased Federal Spending on Medicaid under the ACA
Defendants boast of substantial increases in federal spending associated with the
ACA’s Medicaid program in comparison to the relatively “small outlays” required of the
34
States, DMSJ at 39, but this is no defense to Plaintiff States’ coercion claim. As noted
above, the States depend on the return to them, through Medicaid grants, of the vast
resources taken from their citizens and businesses by the federal government. That the
federal government is increasing Medicaid outlays under the ACA – on condition that the
States accept the new Medicaid regime or lose all Medicaid funding – only strengthens
the conclusion that the federal government has made the States an offer they cannot
refuse. If ever there were to be a “financial inducement offered by Congress … [that]
pass[es] the point at which ‘pressure turns into compulsion[,]’” Dole, 483 U.S. at 211
(quoting Steward Mach. Co. v. Davis, 301 U.S. 548, 590 (1937)), this is it. The ACA
surely represents the very danger that prompted Justice O’Connor, in her dissent in Dole,
to warn that the “vast financial resources of the Federal Government” could permit
Congress under the guise of the Spending Clause “‘to tear down the barriers [and] to
invade the states’ jurisdiction….’” 483 U.S. at 217 (O’Connor, J., dissenting) (quoting
United States v. Butler, 297 U.S. 1, 78 (1936)).
Protection against undue coercion is especially warranted here, where
participation in the ACA’s program will harm the Plaintiff States in serious ways. While
Defendants belittle the increase in State spending required by the ACA (“just 1.4 percent”
over current projected spending, DMSJ at 40), this increase – on top of already spiraling
Medicaid spending obligations – threatens the States’ fiscal viability and ability to fund
other significant priorities. Even before the ACA, Medicaid imperiled State budgets with
substantial increased spending projections at an annual average rate of 7.9 percent
through 2019 (and 9.9% just in 2009). CMS, National Health Expenditure Projections
35
2009-2019, https://www.cms.gov/NationalHealthExpendData/downloads/ proj2009.pdf,
at 1-2 (last visited Nov. 23, 2010). Federal Medicaid officials concede that “[h]igh and
increasing Medicaid spending clearly leaves states less able to fund other state priorities.”
CMS, Medicaid Spending Projected to Rise Much Faster Than the Economy,
http://www.hhs.gov/news/press/2008pres/10/20081017a.html (last visited Nov. 23, 2010)
(quoting Acting CMS Administrator Kerry Weems).
Other federal authorities simultaneously acknowledge the terrible condition of
State finances and their large projected budget gaps (currently up to 41 percent in Fiscal
Year 2010).21
21 Pl.App. Ex. 35 (Policies for Increasing Economic Growth and Employment in 2010 and 2011, Cong. Budget Off., Jan. 2010) at 13, 16 (figure 4); see also State Fiscal Conditions & Medicaid, Kaiser Comm’n, http://www.kff.org/medicaid/upload/7580-06.pdf (including current gaps and those already closed by states, budget shortfalls total $350 billion for 2010 and 2011).
Already-increasing Medicaid obligations combined with then-current
Medicaid and healthcare induced budget stress left Federal Reserve Chairman Ben
Bernanke to conclude that “State budgets will probably remain under substantial pressure
for a while, leaving governors and legislatures a difficult juggling act as they try to maintain
essential services while meeting their budgetary obligations.” Pl.App. Ex. 34 (Bd. of
Governors of the Federal Reserve System, Challenges for the Economy and State
Governments, Aug. 2, 2010) at 6; see also The Long-Term Budget Outlook, CBO, June
2010 (“CBO Budget Outlook”) at 27, available at
http://www.cbo.gov/ftpdocs/115xx/doc11579/06-30-LTBO.pdf (last visited Nov. 23,
2010) (“state governments – which pay a large share of Medicaid’s costs and have
considerable influence on those costs – will need to reduce spending growth in order to
36
balance their budgets”). According to the federal Government Accountability Office
(“GAO”), States must immediately control Medicaid and healthcare costs for many years
ahead to prevent operating deficits – calculated to be $9.9 trillion from 2009 to 2058 –
and persistently cut costs “for each and every year going forward [to achieve] equivalent
to a 12.3 percent reduction in state and local government current expenditures.” Pl.App.
Ex. 38 (State and Local Governments: Fiscal Pressures Could Have Implications for
Future Delivery of Intergovernmental Programs (GAO-10-899), GAO, July 2010) at 6.22
Chairman Bernanke has counseled States to “intensively review the effectiveness of all
programs and be willing to make significant changes to deliver necessary services …
[which is] especially important in the case of health programs, where costs are growing
the most quickly.” Bernanke, supra, at 12.23
22 See also Pl.App. Ex. 37 (State and Local Governments’ Fiscal Outlook (GAO-10-358), March 2010) at 8-9:
Because most state and local governments are required to balance their operating budgets, the declining fiscal conditions shown in our simulations suggest [that] these governments will need to make substantial policy changes to avoid growing fiscal imbalances.… The primary driver of fiscal challenges for the state and local government sector continues to be … state and local expenditures on Medicaid and the cost of health insurance for state and local retirees and employees.
23 Another recent report sums up the States’ Medicaid fiscal dilemma as follows:
Medicaid, the $360 billion a year federal-state health program that serves more than 60 million low-income Americans, has emerged as a central factor in the states’ budget and financial crisis. But an even more severe crisis looms ahead, given the steady rise in health care costs, together with higher, recession-induced demand for Medicaid benefits, and the end of $103 billion in federal stimulus aid to states by mid-2011.
In the absence of major reforms and a robust economic recovery, the potential consequences of the growing state Medicaid squeeze are substantial, experts say. States may slide deeper into the red, affecting
37
Thus, even before Congress looked to increase State Medicaid funding by 1.4
percent under the ACA (according to Defendants’ modest projections), the States faced a
grim fiscal outlook under baseline projections that will continue to require swift and
drastic State action. See Kaiser Comm’n on Medicaid & the Uninsured, State Fiscal
Conditions & Medicaid, Feb. 2010, at 3, http://www.kff.org/medicaid/upload/7580-
06.pdf (last visited Nov. 23, 2010) (“nearly every state implemented at least one new
Medicaid policy to control spending in FY 2009 and 2010 … [and m]id-way through FY
2010, 44 states indicated that they were likely to or there was a possibility of additional
Medicaid cuts beyond those planned at the beginning of the state fiscal year”). With
State finances in critical condition, and a widespread existing need for States to cut their
Medicaid costs, Defendants’ attempt to pass off increased State outlays as “relatively
small” and insignificant is disingenuous: “It’s like living in a parallel universe, … [o]n
the one hand, we have federal partners talking about expansion of this program. And at
the state level, we’re looking at a program that we can’t sustain.” Janet Adamy,
Medicaid Stalemate Tests Cash-Strapped States, Wall. St. J., July 13, 2010 (quoting a
Medicaid official in one of the Plaintiff States).
bond ratings and making it more difficult for them to borrow. Deep cuts in kindergarten through grade 12 and higher education spending could make recent teacher layoffs seem relatively trivial. Sharp state tax and user fee increases may be inevitable. Even some anti-big government conservative governors may be forced to seek additional federal aid. And health care for the poor — the basic function of Medicaid — may suffer.
Andrew L. Yarrow, State Budget Crises Mount as Medicaid Rolls Soar, The Fiscal Times, Sept. 8, 2010, available at http://www.kaiserhealthnews.org/Stories/ 2010/September/08/FT-states-budget-crisis-medicaid.aspx (last visited Nov. 23, 2010).
38
In sum, the ACA’s Medicaid program stands to harm the Plaintiff States
substantially, despite Defendants’ contention that it offers a good deal to the States.
2. Increases in State Spending Will Not Be Offset By New Savings Under the ACA
Defendants next make incredible claims that State costs will be more than offset
by savings under the ACA. They would have this Court discount documented costs to
the States from the ACA (which Defendant do not deny, see DSOMF ¶¶ 40, 47) in favor
of indefinite and inaccurate projections of countervailing State savings drawn from an
unsworn analysis from the Executive Office of the President, Council of Economic
Advisers, that was released months prior to anyone knowing the ACA’s final terms,
during the intense campaign for passage of a comprehensive healthcare bill.24
As the sworn declarations from several Plaintiff States’ Medicaid agency
representatives show, the CEA report’s analysis has serious flaws that render Defendants’
savings claims not only unestablished, but unbelievable. PRSOMF at ¶¶ 48-57. For
instance, Defendants boldly assert that “Florida alone is projected to save $377 million
per year.” DMSJ at 41. But the CEA report upon which Defendants exclusively rely
actually shows that virtually none of the “savings” applies to the State of Florida:
• Most of the claimed “savings” – more than $256 million – applies to local governments only, not to the budget of the State of Florida: $187 million for Miami-Dade County, $82 million for Hillsborough County, $660,000 in Duval County, and $5.6 million relating to inter-county reimbursements. See CEA report at 24, 26. The State of Florida will not see any savings from these local
24 CEA Chair Christina Romer deemed herself “the most passionate person for health care reform in the entire White House.” Romer on Health Care Costs: “The Nightmare Scenario is Getting Closer,” June 2, 2009, http://blogs.abcnews.com/politicalpunch/2009/ 06/romer-on-health-care-costs-the-nightmare-scenario-is-getting-closer.html (last visited Nov. 23, 2010).
39
government programs financed through local taxes, though the State may see cost increases as persons switch out of such local programs to Medicaid.
• The CEA report’s “Hidden Tax” ($102 million) figure (pp. 6, 24) erroneously
assumes that the healthcare bill will eliminate uncompensated care altogether. This figure is fatally flawed as Defendants admit, for instance, that 55 percent of current uninsured persons under the federal poverty line will remain uninsured in Florida, DMSJ at 39, and 21 million nationally. See Payments of Penalties for Being Uninsured Under the Patient Protection and Affordable Care Act, CBO, April 22, 2010. The CEA report also bases this estimate on costs borne by both State and local governments, and so it is inaccurate in any event to attribute the full $102 million savings estimate to the State of Florida alone.
See Pl.Supp.App. Exs. 4 (Further Dudek Decl.) & 5 (Pridgeon Decl.). The CEA report
also understates costs by relying on the increase for Medicaid eligibility to 133 percent
above the poverty line, when in fact the ACA as amended raises that criterion to 138
percent, thereby adding millions more Medicaid recipients to States’ rolls. See
Pl.Supp.App. Ex. 1 (Chaumont Further Decl.) ¶ 17 & Ex. 3 (Damler Decl.) at ¶ 11.
In addition, the CEA report forecasts State savings (of $117 million) that “may
come” from the Children’s Health Insurance Program. CEA report at 24-25. But
Florida, for example, already has taken State CHIP-related savings projections into
account in its own forecast (see Pl.App. Ex. 1 (Dudek Decl.) at ¶ 20, wherein Florida
estimates the ACA will cost it more than $1 billion annually by 2018-19; see also
Pl.Supp.App. Ex. 1 (Chaumont Further Decl.) at ¶ 13).
It is no wonder that the CEA report is not even cited by government agencies in
their assessments of projected costs from the ACA. See, e.g., Pl.App. Ex. 39 (Richard S.
Foster, Estimated Financial Effects of the “Patient Protection and Affordable Care Act,”
Centers for Medicare & Medicaid Servs., April 22, 2010); Pl.App. Ex. 36 (Variation in
40
Analyses of PPACA’s Fiscal Impact on States, Cong. Res. Serv., Sept. 8, 2010) at tbl 2;
Def.App. Ex. 32 (CBO Letter to Speaker Pelosi).
Moreover, Defendants’ “savings” projections entirely overlook other potentially
significant additional costs to the States – most dramatically, costs and liabilities from
being required to provide (rather than reimburse the cost of) healthcare services.
However, CMS has indicated that it is “probable initially” that there will be fewer
healthcare providers accepting Medicaid patients:
[I]t is reasonable to expect that a significant portion of the increased demand for Medicaid would be difficult to meet, particularly over the first few years. … For now we believe that consideration should be given the potential consequences of a significant increase in demand for health care meeting a relatively fixed supply of health care providers and services.
Pl.App. Ex. 39 (Estimated Financial Effects of the [ACA], CMS) at 20. The ACA shifts
this problem entirely to the States for them to bear the costs and legal consequences of a
programmatic failure that the federal government thoroughly foresees. This, added to the
general projection of a looming serious doctor shortage, puts the States in an untenable
dilemma: either (1) increase their Medicaid outlays substantially in the hope of attracting
sufficient numbers of providers to furnish all needed services to Medicaid recipients, or
(2) face the consequences for failing to meet this ACA requirement, including potential
massive liabilities and loss of Medicaid funding. Any claim of net “savings” that ignores
such catastrophic consequences is seriously misleading and should be disregarded.
Beyond all of these categories overlooked by Defendants, CRS recognizes that the
ACA could increase States’ costs in the following areas:
• State requirement to maintain existing Medicaid and CHIP eligibility levels (MOE) for adults until exchanges are fully operational (presumably CY 2014) and
41
for children through 2019 as a condition of receiving federal matching funds for Medicaid expenditures;
• State requirement to improve outreach, streamline enrollment, and coordinate with CHIP and proposed exchanges that may increase applications and enrollment among those previously eligible but not yet enrolled, as well as increase administrative costs in the short run (see PRSOMF ¶ 41 n.3 & n.4);
• Federal requirement to reduce Medicaid disproportionate share hospital (DSH)
allotments. While the healthcare reform law is designed to lower the number of low income patients and patients whose care otherwise would be funded in part by DSH payments to hospitals treating such patients, the ACA’s requirement to reduce DSH payments going forward may necessitate increased outlays by States to shore up hospitals against losses;
• Federal requirement to increase the amount of Medicaid drug rebates going to the
federal government. Medicaid law requires prescription drug manufacturers who wish to sell their products to Medicaid agencies to enter into rebate agreements with the HHS Secretary on behalf of states. Beginning January 1, 2010, with certain exceptions, the ACA increases the flat percentage used to calculate Medicaid’s basic rebate by an amount that varies by drug class. The ACA also requires the Secretary to recover the additional funds States received from drug manufacturers due to increases in the basic Medicaid rebates (some of which were previously retained by States).
Pl.App. Ex. 36 (Variation in Analyses, CRS) at 4-5; see also PSOMF ¶¶ 15, 21, 24-27.
In sum, the notion that the States could achieve net savings under the ACA is both
unsupported and preposterous. See PRSOMF ¶¶ 57-58 (disputing two other papers that
Defendants cite in passing in DMSJ at 41 n.12). No credible assessment of the ACA’s
projected impact forecasts any such thing. And, as noted, none places a dollar value on
the ACA’s requirement that States provide healthcare services under the new Medicaid
regime, or on the harm to State budgets from the ACA’s maintenance-of-effort provisions
that remove their ability to cut costs by revising (formerly) optional eligibility categories.
Moreover, even if the States were projected to achieve collateral savings, those
savings would in no way lessen the coercion and commandeering of which Plaintiff
42
States complain, because they still would be required to do Congress’s bidding, and to
incur costs and liabilities under the ACA’s new Medicaid regime, as noted above.
C. Plaintiffs States’ Coercion Claim Is Justiciable and Fit for Judicial Resolution in Plaintiffs’ Favor
Their other contentions unavailing, Defendants rehash their argument that
coercion claims are nonjusticiable. However, this Court already has analyzed
Defendants’ argument and the viability of the coercion doctrine, and concluded that the
Plaintiff States’ claim is not foreclosed in this circuit or by Supreme Court precedent:
If the Supreme Court meant what it said in Dole and Steward Machine Co. (and I must presume that it did), there is a line somewhere between mere pressure and impermissible coercion. The reluctance of some circuits to deal with this issue because of the potential legal and factual complexities is not entitled to a great deal of weight, because courts deal every day with the difficult complexities of applying Constitutional principles set forth and defined by the Supreme Court. … [T]he plaintiffs have stated a “plausible” claim in this circuit.
Mem.Op. at 56-57.
Moreover, as recently as 1999, the Supreme Court acknowledged the viability of
coercion claims based on financial inducement in a case that closely divided on the
question of whether a federal act unlawfully could “coerce” a State to waive its sovereign
immunity as a condition of pursuing lawful activity. Coll. Sav. Bank v. Fla. Prepaid
Postsecondary Educ. Expense Bd., 527 U.S. 666, 687 (1999). Although College Savings
Bank did not involve financial inducement, the Court noted that where Congress
threatens to withhold “substantial” funds unless a State agrees to its conditions, “‘the
financial inducement offered by Congress might be so coercive as to pass the point at
which ‘pressure turns into compulsion.’” Id. (quoting Dole, 483 U.S. at 211, and
43
Machine, 301 U.S. at 590). Thus, this Court again should reject Defendants’ argument
that coercion claims are nonjusticiable.
Defendants add a divide-and-conquer argument that the ACA-transformed
Medicaid program might be coercive for some States, but not for others. DMSJ at 44-45.
Of course, federal bullying of less-populated States (Defendants attempt to peel off, for
instance, Alaska and Wyoming) with the “single largest Federal grant-in-aid program to
the States, accounting for over 40 percent of all Federal grants to States”25 still would
constitute unlawful coercion. Even though the nature and scope of Medicaid programs
and funding differ according to States’ policies, sizes, and priorities, federal support for
the Medicaid programs in all States is quite substantial, amounting to hundreds of
millions or billions of dollars annually in State budgets and averaging more than 20
percent of total State spending nationally.26
Moreover, it is no answer that State Medicaid spending levels in the Plaintiff
States fall at different places on a “substantial impact continuum” from 8.4 percent of
Alaska’s total State spending to more than 30 percent of Pennsylvania’s. In either case,
and for all States in-between, Congress’s threat to withhold significant percentages of
State funding easily meets and exceeds the unlawful financial inducement threshold.
That is, the threat to exclude citizens in any State from this enormous program –
25 Bipartisan Comm’n on the Medicaid Act of 2005, H.R. 985, 109th Cong. § 2(13) (2005); see also Pl.App. Exs. 32-33 (CMS letters to Arizona). 26 See http://www.statehealthfacts.org/comparereport.jsp?rep=45&cat=17 (last visited Nov. 23, 2010); http://www.hhs.gov/recovery/statefunds.html (last visited Nov. 23, 2010) (more than $15 billion additional federal Medicaid dollars were distributed to the States in 2009).
44
consuming some seven percent of all federal outlays ($251 billion in 2010)27
Regardless of which State is considered, federal Medicaid funding dwarfs the $4
million in highway grant funds at stake in Dole that the Supreme Court found to be
merely “mild encouragement.” 483 U.S. at 211. Indeed, the Medicaid program dangles
total funding that is twelve times higher than the amounts that Justice Breyer and three
other justices considered “compelling and oppressive” in College Savings Bank. 527
U.S. at 697 (Breyer J. dissenting) (suggesting coercion with respect to $20 and $21
billion programs). Thus, whatever quibbles Defendants have as to exactly how large a
lesser financial inducement must be to trigger application of the coercion doctrine need
not be resolved here, because Medicaid is not a marginal spending program. The ACA
coerces States with the single largest federal grant-in-aid program to the States.
and funded
with federal taxes paid by citizens from all States – would constitute unlawful coercion
even for a State that spends comparatively less of its budget on Medicaid.
The unprecedented financial coercion apparent in the ACA’s unilaterally
transformed Medicaid program, combined with the absence of a defined mechanism for
States to exit the program (discussed further below), establishes the Plaintiff States’
coercion claim and forecloses summary judgment for the Defendants.
D. The ACA’s Medicaid Program Is Unlawfully Coercive
Defendants’ final argument also essentially restates their view that coercion
claims are nonjusticiable, citing to those circuit court decisions that have so ruled. DMSJ
at 47-50. Defendants assert that the size of a federal grant does not matter, the proportion 27 CBO Budget Outlook at 30; Citizen’s Guide to the Federal Budget, http://www.gpoaccess.gov/usbudget/fy01/guide02.html (last visited Nov. 23, 2010).
45
of federal funding does not matter, and the importance of the federal grant does not
matter; in sum, and contrary to this Court’s prior ruling, they believe that a State cannot
establish an unlawful coercion claim on any set of facts. Defendants’ citation to Steward
Machine does not help their argument, as that case did not involve direct and drastic
consequences for State budgets, but only encouragement for States to administer an
unemployment compensation program funded by taxes on employers. Moreover,
Steward Machine involved a wholly new program and decision for the States, and not
Congress’s strategic transformation of a large and long-established program to force
States into making a destructive Hobson’s choice affecting millions of needy recipients.
Here, Plaintiff States must either accept the ACA’s radically changed Medicaid,
or (1) forgo billions of dollars annually, which the federal government collects from State
taxpayers and then returns as Medicaid funds to the States; and (2) risk the welfare of
their most vulnerable citizens, and the continuing vitality of their healthcare
infrastructure, by attempting to opt out of Medicaid without any defined transition
process or established programmatic alternative. No federal program besides Medicaid
funds healthcare services for the States’ poorest and neediest residents, and the States
plainly are unable to establish, fund, and implement a Medicaid-like replacement
program, much less to do so immediately to safeguard needy Medicaid recipients
dropped by the federal program.
The prospect of losing these vast sums coerces Plaintiff States not only because of
the unprecedented funding levels at stake, but also because Congress has deprived
Plaintiff States of the ability to replace their current Medicaid programs. As noted, the
46
Court has identified this critical aspect of the ACA’s program: the federal government
“has little money except through taxpayers, who almost exclusively reside within the
states,” and if federal Medicaid funds are withheld the tax revenues collected in the States
who opt out will be diverted to other, more compliant States. Mem.Op. at 56.
Plaintiff States cannot make up this shortfall. In particular, they cannot simply
raise State taxes as Defendants suggest in citing Nevada v. Skinner, 884 F.2d 445, 448
(9th Cir. 1989).28 DMSJ at 47. In Florida, as an example, State tax collections in 2009
totaled less than $32 billion, whereas IRS collections from Florida were $110 billion.29
In 2010, Florida will spend more than $20 billion on Medicaid, toward which the federal
government is expected to return to Florida more than $12 billion.30 For Florida now to
opt out of Medicaid and itself provide the same $20 billion in benefits would consume
more than half of its tax revenues (up from 19 percent currently), not counting the
significant costs associated with administering such a program.31
28 Indeed, federal policymakers suggest that raising State tax increases would only compound the States’ fiscal dilemma, and provided federal aid for the very purpose of keeping the States from raising taxes. See Christina D. Romer, Back to a Better Normal: Unemployment and Growth in the Wake of the Great Recession, Council of Economic Advisors, April 17, 2010 at 9, available at http://www.whitehouse.gov/ sites/default/files/rss_viewer/back_to_a_better_normal.pdf (last visited Nov. 23, 2010).
29 See http://www.census.gov/govs/statetax/0910flstax.html (last visited Nov. 23, 2010); http://www.irs.gov/taxstats/article/0,,id=206488,00.html (last visited Nov. 23, 2010). 30 See Pl.App. Ex. 4 (Leznoff Decl.). 31 CMS requested $725 million for 2011 to administer Medicaid and other programs. See CMS, Justification of Estimates for Appropriations Comm., FY 2011, at 28-29, https://www.cms.gov/PerformanceBudget/Downloads/CMSFY11CJ.pdf (last visited Nov. 23, 2010).
47
Replacing these revenues would necessitate unfathomable State tax increases
(more than 50 percent in Florida), from populations which must continue to pay federal
taxes. This alone sets this case far apart from any previous coercion claims rejected by
various circuit courts, and exceeds even the “compelling and oppressive” scenarios
outlined by Justice Breyer in College Savings Bank.32
Unlike any of the cases cited by the Defendants, these weighty and incontestable
constraints unlawfully force the Plaintiff States to participate in the ACA’s new Medicaid
regime, and to assume billions of dollars of unaffordable new costs and other costly
responsibilities against their will. In subjecting Plaintiff States to this unprecedented
Hobson’s choice, Congress has exceeded its Article I powers and violated fundamental
principles of federalism, the Ninth and Tenth Amendments, and the Guarantee Clause.
The illusory “choice” offered to the States goes far beyond the point at which persuasion
becomes coercion under Dole. Congress, having made captives of the States,
Moreover, there are both practical
and legal constraints on Florida’s ability to raise additional revenue of the magnitude
required to replace federal Medicaid payments to the State. See Pl.App. Exs. 4 (Leznoff
Decl.) & 5 (Watkins Decl.).
32 Nor is debt-financing of recurring expenses a sustainable option for enabling States that opt out of Medicaid to provide comparable services without federal funding. “Most states have already borrowed as much as they can under their own budget rules and will probably remain up against those limits during the next few years.” Pl.App. Ex. 35_ (CBO, Policies for Increasing Economic Growth and Employment in 2010 and 2011, Jan. 2010) at 13, 16 (figure 4). As Federal Reserve Chairman Ben S. Bernanke notes: “the balanced budget rules followed by 49 of the 50 states … provide important discipline and are a key reason that states have not built up long-term debt burdens comparable to those of many national governments.” Pl.App. Ex. 34 (Challenges for the Economy and State Governments) at 6.
48
impermissibly commandeers Plaintiff States into funding and administering a new federal
program contrary to New York v. United States, 505 U.S. 144 (1992), and Printz.
E. The ACA Violates All Five Dole Spending Clause Restrictions
Moreover, imposition of the ACA’s Medicaid regime on the States violates all
restrictions on Congress’s Article I, section 8 spending power under Dole, 483 U.S. at
207-08.
First, the Hobson’s choice imposed on the States – to give way to federal dictates
or attempt to withdraw from Medicaid – cannot reasonably be characterized as furthering
the general welfare. Either way, the States’ ability to aid the poor will be impaired,
because their participation in the ACA-altered Medicaid program threatens to leave them
without the resources to provide medical care to indigents, while withdrawal would leave
no federally-funded indigent care program at all, and the States alone cannot afford to
offer Medicaid-level benefits.
Second, Congress did not condition Medicaid funds on unambiguous terms: the
ACA’s sweeping changes could not reasonably have been foreseen by the States when
they started their Medicaid programs or later chose to add costlier optional elements.
Third, the ACA’s altered and expanded conditions – a critical component of a
new universal healthcare regime – change the fundamental purpose for which Medicaid
was established: viz., as a means to aid the States’ poorest residents.
Fourth, the ACA violates State sovereignty and federalism principles, as shown.
Fifth, the ACA unlawfully coerces the States, for all the reasons discussed above.
49
Because the ACA exceeds every restriction on Congress’s spending power,
Defendants’ claim for summary judgment in their favor on Count Four must be denied.
III. THE ACA MUST BE STRUCK DOWN IN ITS ENTIRETY The Individual Mandate cannot be severed from the ACA’s other provisions. It is
the centerpiece of Congress’s effort to provide for universal national healthcare
insurance, DMTD [Doc. 55-1] at 5, 7, 46-48, and Congress clearly would not have
enacted the ACA without the mandate. Based on the statute’s text, history, and
legislative purpose, without the Individual Mandate Congress “would have preferred ...
no statute at all[.]” Ayotte v. Planned Parenthood of No. New England, 546 U.S. 320,
330 (2006).
And, of course, it is highly significant that Congress, in crafting one of the most
sweeping federal statutes in decades, did not include a severability clause in the ACA.
Although the absence of such a provision does not bind the Court, see, e.g., Alabama
Power Co. v. U.S. Dept. of Energy
Likewise, the ACA’s Medicaid regime constitutes one of four “doors” through
which an individual may pass to obtain qualified coverage in order to comply with the
Individual Mandate. Hence, the Medicaid regime is essential to the Act’s architecture:
remove it, and there is no provision for the Nation’s tens of millions of poor and needy
, 307 F.3d 1300, 1308 (11th Cir. 2002), in this case it
strongly suggests that Congress would not “have preferred what is left” of the Act
without the Individual Mandate. See Ayotte, 546 U.S. at 330. Cf. Brockett v. Spokane
Arcades, 472 U.S. 491, 506 (1985) (citing severability clause as an important factor
favoring partial rather than facial invalidation of statute).
50
persons to comply with the mandate. Because the Act cannot function independent of its
Medicaid provisions, those provisions cannot be severed. See Alaska Airlines, Inc. v.
Brock, 480 U.S. 678, 684-86 (1987); Hill v. Wallace, 259 U.S. 44, 70 (1922). It is
therefore unreasonable to infer that Congress would have passed the ACA in the absence
of its Medicaid provisions. See Ayotte v. Planned Parenthood of Northern New England,
546 U.S. 320, 330-32 (2006). Consequently, the unconstitutionality of the Act’s
Medicaid regime requires that the entire ACA be struck down.
Conclusion
For all the reasons stated above, Defendants’ motion for summary judgment
should be denied.
Respectfully submitted,
BILL MCCOLLUM ATTORNEY GENERAL OF FLORIDA
/s/ Blaine H. Winship Blaine H. Winship (Fla. Bar No. 0356913) Special Counsel Joseph W. Jacquot (Fla. Bar No. 189715) Deputy Attorney General Scott D. Makar (Fla. Bar No. 709697) Solicitor General Louis F. Hubener (Fla. Bar No. 0140084) Timothy D. Osterhaus (Fla. Bar No.
0133728) Deputy Solicitors General Office of the Attorney General of Florida The Capitol, Suite PL-01 Tallahassee, Florida 32399-1050 Telephone: (850) 414-3300 Facsimile: (850) 488-4872 Email: [email protected] Attorneys for Plaintiff States
51
David B. Rivkin (D.C. Bar No. 394446) Lee A. Casey (D.C. Bar No. 447443) Baker & Hostetler LLP 1050 Connecticut Avenue, N.W., Ste. 1100 Washington, DC 20036 Telephone: (202) 861-1731 Facsimile: (202) 861-1783 Attorneys for Plaintiff States, National Federation of Independent Business, Mary Brown, and Kaj Ahlburg Katherine J. Spohn Special Counsel to the Attorney General Office of the Attorney General of Nebraska 2115 State Capitol Building Lincoln, Nebraska 68508 Telephone: (402) 471-2834 Facsimile: (402) 471-1929 Email: [email protected] Attorneys for Plaintiff the State of Nebraska Karen R. Harned Bill Cobb Executive Director Deputy Attorney General National Federation of Independent for Civil Litigation Business Office of the Attorney General of Texas Small Business Legal Center P.O. Box 12548, Capitol Station 1201 F Street, N.W., Suite 200 Austin, Texas 78711-2548 Washington, DC 20004 Telephone: (512) 475-0131 Telephone: (202) 314-2061 Facsimile: (512) 936-0545 Facsimile: (202) 554-5572 Email: [email protected] Of counsel for Plaintiff National Attorneys for Plaintiff the State of Texas Federation of Independent Business
52
CERTIFICATE OF SERVICE I hereby certify that, on this 23rd day of November, 2010, a copy of the foregoing
Plaintiffs’ Memorandum in Opposition to Defendants’ Motion for Summary Judgment
was served on counsel of record for all Defendants through the Court’s Notice of
Electronic Filing system.
/s/ Blaine H. Winship Blaine H. Winship Special Counsel Office of the Attorney General of Florida
IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF FLORIDA
Pensacola Division
STATE OF FLORIDA, by and through Bill McCollum, et al., Plaintiffs, v. Case No.: 3:10-cv-91-RV/EMT UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, et al., Defendants. ___________________________________________/
SUPPLEMENTAL APPENDIX OF EXHIBITS IN SUPPORT OF PLAINTIFFS’ MEMORANDUM IN OPPOSITION TO DEFENDANTS’ MOTION FOR
SUMMARY JUDGMENT
Plaintiffs hereby submit this Supplemental Appendix of Exhibits in Support of Plaintiffs’
Memorandum in Opposition to Defendants’ Motion for Summary Judgment.
Respectfully submitted,
BILL MCCOLLUM ATTORNEY GENERAL OF FLORIDA
/s/ Blaine H. Winship Blaine H. Winship (Fla. Bar No. 0356913) Special Counsel Joseph W. Jacquot (Fla. Bar No. 189715) Deputy Attorney General Scott D. Makar (Fla. Bar No. 709697) Solicitor General Louis F. Hubener (Fla. Bar No. 0140084) Timothy D. Osterhaus (Fla. Bar No. 0133728) Deputy Solicitors General Office of the Attorney General of Florida The Capitol, Suite PL-01 Tallahassee, Florida 32399-1050 Telephone: (850) 414-3300 Facsimile: (850) 488-4872 Email: [email protected] Attorneys for Plaintiff States David B. Rivkin (D.C. Bar No. 394446) Lee A. Casey (D.C. Bar No. 447443) Baker & Hostetler LLP 1050 Connecticut Avenue, N.W., Ste. 1100 Washington, DC 20036 Telephone: (202) 861-1731 Facsimile: (202) 861-1783 Attorneys for Plaintiff States, National Federation of Independent Business, Mary Brown, and Kaj Ahlburg Katherine J. Spohn Special Counsel to the Attorney General Office of the Attorney General of Nebraska 2115 State Capitol Building Lincoln, Nebraska 68508 Telephone: (402) 471-2834 Facsimile: (402) 471-1929 Email: [email protected] Attorneys for Plaintiff the State of Nebraska
2
3
Karen R. Harned Bill Cobb Executive Director Deputy Attorney General National Federation of Independent for Civil Litigation Business Office of the Attorney General of Texas Small Business Legal Center P.O. Box 12548, Capitol Station 1201 F Street, N.W., Suite 200 Austin, Texas 78711-2548 Washington, DC 20004 Telephone: (512) 475-0131 Telephone: (202) 314-2061 Facsimile: (512) 936-0545 Facsimile: (202) 554-5572 Email: [email protected] Of counsel for Plaintiff National Attorneys for Plaintiff the State of Texas Federation of Independent Business
CERTIFICATE OF SERVICE
I hereby certify that, on this 23rd day of November, 2010, a copy of the foregoing Supplemental Appendix of Exhibits in Support of Plaintiffs’ Memorandum in Opposition to Defendants’ Motion for Summary Judgment was served on counsel of record for all Defendants through the Court’s Notice of Electronic Filing system. /s/ Blaine H. Winship Blaine H. Winship Special Counsel
TABLE OF EXHIBITS
Exhibit No.
1 Chaumont Declaration
2 Church Declaration
3 Damler Declaration
4 Dudek Declaration
5 Pridgeon Declaration
6 Ramge Declaration
7 Excerpt from Kaiser Commision on Medicaid and the Uninsured (June 2005),
“Medicaid Enrollment andSpending by “Mandatory” and “Optional” Eligibility and
Benefit Categories”
Exhibit 1
Exhibit 2
Exhibit 3
Exhibit 4
Exhibit 5
Exhibit 6
Exhibit 7
medicaid
kaiser commiss ion o n
uninsureda n d t h e
Medicaid Enrollment and Spending by “Mandatory” and “Optional” Eligibility and Benefit Categories
prepared by Anna Sommers, Ph.D. Arunabh Ghosh, B.A. The Urban Institute and David Rousseau, M.P.H. The Kaiser Commission on Medicaid and the Uninsured
June 2005
Mandatory and Optional Medicaid Spending In 2001, Medicaid spent $203.8 billion on acute and long-term care services for low-income families, individuals with disabilities, and the elderly (Figure 4). This includes $5.0 billion of mandatory payments to Medicare for individuals dually eligible for Medicaid and Medicare, in the form of premiums, copayments, and coinsurance. Of the $203.8 billion in Medicaid expenditures, 39.4% was mandatory, or spending on mandatory benefits for mandatory eligibility groups. The remaining 60.6% was considered optional spending: 18.1% of spending was on optional benefits for mandatory groups, 30.1% was for mandatory benefits for optional groups, and 12.3% was for optional benefits for optional groups.
Figure 4
Medicaid Expenditures by Eligibility Group and Type of Service, 2001
Mandatory
Optional
Total = $203.8 billion
NOTE: Total expenditures do not include disproportionate share hospital (DSH) payments, administrative costs, or accounting adjustments.
39.4%
12.3%
30.1%
18.1%
Optional Services for Mandatory Groups
Mandatory Services for Optional Groups
Mandatory Services for Mandatory Groups
Optional 6 0 .6%
Optional Services for Optional Groups
SOURCE: Urban Institute Estimates based on FFY data from MSIS 2001 and CMS 64 reports.
A total of $80.4 billion was spent on mandatory services for mandatory groups in 2001 (Figure 5). The vast majority of mandatory spending, 78 percent or $62.6 billion, was attributable to acute care services other than prescription drugs. Over 90% of these expenditures were attributable to “major” acute care services, defined as inpatient, outpatient hospital, physician, lab/x-ray, clinic, and managed care services. Long-term care accounted for 16% of all mandatory spending, of which just over half (54%) was for nursing facility care. Payments to Medicare for premiums and coinsurance for mandatory dual eligible individuals accounted for nearly 4% of mandatory spending. A total of $123.4 billion was spent on optional services for mandatory groups combined with all spending for optional groups in 2001 (Figure 5). Nearly sixty percent of all of this optional spending (57.3%) was attributable to long-term care. Payments to Medicare for premiums and coinsurance for optional dual eligible
11
IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF FLORIDA
Pensacola Division
STATE OF FLORIDA, by and through Bill McCollum, et al., Plaintiffs, v. Case No.: 3:10-cv-91-RV/EMT UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, et al., Defendants. ___________________________________________/
PLAINTIFFS’ RESPONSE TO DEFENDANTS’ STATEMENT OF FACTS
AS TO WHICH THERE IS NO GENUINE ISSUE
Pursuant to Rule 56, Federal Rules of Civil Procedure, and Rule 56.1(A), Rules of the
United States District Court for the Northern District of Florida, Plaintiffs hereby submit this
Response to Defendants’ Statement of Facts As to Which There Is No Genuine Issue [No. 82-2]
(“DSOMF”). As shown below and in Plaintiffs’ Memorandum in Opposition to Defendants’
Motion for Summary Judgment, Defendants’ asserted facts are either legally or factually
irrelevant to the issues presented, or are demonstrably lacking in support or credibility, and thus
fail to give rise to any genuine issue of material fact. Consequently, Defendants’ asserted facts
cannot prevent entry of summary judgment in Plaintiffs’ favor on their facial constitutional
challenge to the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119
(2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No.
111-152, 124 Stat. 1029 (2010) (“ACA”). True and correct copies of all referenced exhibits (and
attachments thereto) are contained in Plaintiffs’ accompanying Supplemental Appendix.
Preliminary Statement: Plaintiffs begin by taking the opportunity to respond to preliminary statements included
in DSOMF.
Defendants cite Gonzales v. Raich, 545 U.S. 1, 16-17 (2005) out of context in suggesting
that this Court’s only task is to determine whether Congress had a “‘rational basis’ to conclude
that the class of activities it undertook to regulate, when taken in the aggregate, has a substantial
effect on interstate commerce.” DSOMF at 1.
Plaintiffs’ citation of authority to the effect that “legislative facts” are not subject to
courtroom proof is inapposite. This case does not concern a challenge to legislative facts. The
economic consequences of some individuals not having healthcare insurance are immaterial to
Plaintiffs’ core argument in support of Count One, which is that whatever the alleged economic
consequences of a particular individual’s failure to have healthcare coverage, regulation of this
lack of insurance is beyond the constitutional limits of the Commerce Clause.
As explained by the Supreme Court, the presence of economic activity is a key limit on
Congress’s power to regulate under the Commerce Clause. See United States v. Lopez, 514 U.S.
549, 558 (1995) (demarcating “three broad categories of activity that Congress may regulate
under its Commerce Clause power”). Whether being uninsured is subject to the commerce
power as is a legal, and not a factual, question going directly to Congress’s authority to enact the
Individual Mandate. Congress may not evade the constitutional limits on its power, or escape
judicial review, by dressing its legal conclusions in the garb of legislative “facts.” E.g., ACA §
1501(a)(2)(A) (finding that the Individual Mandate regulates “activity that is commercial and
economic in nature: economic and financial decisions about ... health insurance”). Rather, the
limits of Congress’s authority under the Constitution are a question of law upon which the
2
judiciary, not Congress, must have the last word. See generally Cooper v. Aaron, 358 U.S. 1, 18,
(1958) (noting the “permanent and indispensable feature of our constitutional system” that “the
federal judiciary is supreme in the exposition of the law of the Constitution”). See also
Lamprecht v. FCC, 958 F.2d 382, 392 n.2 (D.C. Cir. 1992) (Thomas, J.) (“If a legislature could
make a statute constitutional simply by “finding” that black is white or freedom, slavery, judicial
review would be an elaborate farce.”).
Defendants also are incorrect in stating that the ACA’s Medicaid Amendments’ costs to
the states are immaterial to the resolution of Count Four at summary judgment. Plaintiff States’
sovereignty will be unconstitutionally impaired if they are forced to comply with the ACA’s
Medicaid provisions, quite apart from whether or not this compulsion is sufficient to meet the
standards of South Dakota v. Dole, 483 U.S. 203 (1987). See PMSJ [Doc 80-1] at 39
(“[R]emaining in the ACA Medicaid program will encumber the Plaintiff States with such
massive new expenses and responsibilities that their viability as sovereigns will be severely
threatened”) & 42 (“Having to comply with these requirements will fundamentally undermine
Plaintiff States’ abilities to function as sovereigns.”). The ACA’s Medicaid Amendments’ costs
to the States are therefore material to the Court’s resolution of Count Four at summary judgment.
Responses To Defendants’ Asserted Facts:
For the convenience of the Court, Plaintiffs have followed the paragraph numbering and
organization of Defendants’ submission. Plaintiffs respond individually to Defendants’ asserted
material undisputed facts as follows:
I. Defendants’ Asserted Facts Pertaining To The Minimum Coverage Provision
1. Congress gave detailed consideration to the structure of the reforms of the interstate health insurance market that it enacted in the ACA, as shown by the more than fifty hearings that
3
it held on the subject in the 110th and 111th Congresses alone. See H.R. Rep. No. 111-443, pt. II, at 954-68 (2010) (Ex. 1)
Response: This statement is disputed. Plaintiffs do not agree with Defendants’ characterization of the genesis of the ACA. As noted by this Court, Congress’s consideration of the ACA was widely criticized for being “drafted behind closed doors and pushed through Congress by parliamentary tricks, late night weekend votes, and last minute deals among members of Congress who did not read or otherwise know what was in it.” See Mem.Op. [Doc. 79] at 2. H.R. Rep. No. 111-443, pt. II speaks for itself and Plaintiffs decline to characterize its contents.
2. In 2009, the United States spent more than an estimated 17 percent of its gross domestic product on health care. ACA §§ 1501(a)(2)(B), 10106(a).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph, except to admit that it is contained in the cited ACA sections. However, the statement is irrelevant and immaterial to the constitutionality of the Individual Mandate.
3. Notwithstanding these expenditures, 45 million people — an estimated 15 percent of the population — went without health insurance for some portion of 2009. Absent the new statute, that number would have climbed to 54 million by 2019. Cong. Budget Office (“CBO”), Key Issues in Analyzing Major Health Insurance Proposals 11 (Dec. 2008) [hereinafter Key Issues] (Ex. 2); see also CBO, The Long-Term Budget Outlook 21-22 (June 2009) (Ex. 3).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, however they are irrelevant and immaterial to the constitutionality of the Individual Mandate. Cong. Budget Office, Key Issues in Analyzing Major Health Insurance Proposals, (Dec. 2008) (“Key Issues”) and CBO, The Long Term Budget Outlook (June 2009) speak for themselves and Plaintiffs decline to characterize their contents.
4. The pervasive lack of insurance occurred because “[t]he market for health insurance . . . is not a well-functioning market.” Council of Economic Advisers (“CEA”), The Economic Case for Health Care Reform 16 (June 2009) (submitted into the record for The Economic Case for Health Reform: Hearing Before the H. Comm. on the Budget, 111th Cong. 5 (2009)) [hereinafter The Economic Case] (Ex. 4).
Response: It is undisputed that the President’s Council of Economic Advisers believes that the market for health insurance “is not a well-functioning market.” However, as “Congress has recognized: ‘By most measures, we have the best medical care system in the world.’” Mem.Op. at 3. Plaintiffs dispute the implication that there is a causal connection between the lack of insurance and any market failures identified by CEA. Plaintiffs also dispute Defendants’ characterization that there is a “pervasive lack of insurance” because of the “market failures” identified by CEA. CEA refers simply to “a large number of individuals and families without health insurance.” In addition, the averments in this paragraph are irrelevant and immaterial to the constitutionality of the Individual Mandate. Council of
4
Economic Advisers (“CEA”), The Economic Case for Health Care Reform (June 2009) (“The Economic Case”) and the record of The Economic Case for Health Reform: Hearing Before the H. Comm. on the Budget, 111th Cong. (2009).
5. With rare exceptions, individuals cannot make a personal choice to eliminate the current or potential future consumption of health care services. Nor can individuals reliably predict whether they or their families will need health care. They may go without health care for some time, then unexpectedly suffer a debilitating injury or disease and suddenly incur high or even catastrophic health care costs. See J.P. Ruger, The Moral Foundations of Health Insurance, 100 Q.J. Med. 53, 54-55 (2007) (Ex. 5). In this market, everyone is a participant because everyone, in one way or another, is faced with managing the financial risks associated with unpredictable future health care costs. Katherine Baicker & Amitabh Chandra, Myths and Misconceptions About U.S. Health Insurance, 27 Health Affairs w533, w534 (2008) (Ex. 6); Jonathan Gruber, Public Finance and Public Policy 442-28 (3d ed. 2009) (Ex. 7).
Response: The averments in this paragraph constitute Defendants’ characterizations of the undisputed facts that a majority of human beings will, at some point in their lives, seek and/or receive medical attention, and that life is uncertain. Plaintiffs dispute Defendants’ claims that everyone is a participant in the market for medical services or health care because they must “manage[] the financial risks associated with unpredictable future health care costs.” This constitutes Plaintiffs characterization of the above-referenced statements and also constitutes a legal conclusion for purposes of this case. Finally, the authorities cited by Defendants are without foundation and do not support their contention, but merely offer explanations of the insurance industry in general and healthcare insurance industry in particular.
6. When a person does fall ill, he is effectively assured of at least a basic level of emergency care, without regard to his insured status. See, e.g., Fla. Stat. § 395.1041 (2004) (“The Legislature finds and declares it to be of vital importance that emergency services and care be provided by hospitals and physicians to every person in need of such care”); Emergency Medical Treatment and Labor Act, 42 U.S.C. § 1395dd (hospitals that participate in Medicare and offer emergency services are required to stabilize, or provide an appropriate transfer for, any patient who arrives, regardless of whether he has insurance or otherwise can pay for that care); CBO, Key Issues, at 13. In addition, most hospitals are nonprofit organizations that “have some obligation to provide care for free or for a minimal charge to members of their community who could not afford it otherwise.” Id. For-profit hospitals “also provide such charity or reduced-price care.” Id.
Response: It is undisputed that there are various federal and state requirements that covered hospitals and other healthcare providers treat individuals in need of certain, minimal emergency services. Plaintiffs, however, dispute the implication that this amounts to a guarantee of free health are services for anyone who “fall[s] ill.” In addition, the averments in this paragraph are irrelevant and immaterial to the constitutionality of the Individual Mandate. Fla. Stat. § 395.1041 (2004), 42 U.S.C. § 1395dd, and the CBO’s Key Issues report all speak for themselves.
5
7. Because of the availability of this backstop of free care, many persons have an incentive not to obtain insurance, knowing that they will not bear the full cost of their decision to attempt to pay for their health care needs out-of-pocket. The Economic Case, at 17; see also Bradley Herring, The Effect of the Availability of Charity Care to the Uninsured on the Demand for Private Health Insurance, 24 J. of Health Econ. 225, 226 (2005) (Ex. 10).
Response: The averments in this paragraph are irrelevant and immaterial to the constitutionality of the Individual Mandate and are based on authorities that are without foundation. It is undisputed that the availability of certain, minimal emergency care services could serve as an incentive for some individuals to forgo healthcare insurance coverage. However, Plaintiffs dispute Defendants’ implication that this is the only reason, or even a particularly important reason, for being uninsured. As Defendants’ own authority explains in detail, there are several “factors” that lead to people not having healthcare insurance coverage. The most important of these, according to the President’s CEA, is “adverse selection” by insurance companies:
An insurance company will not price individual health insurance at the average cost of covering the uninsured. If it did, the individuals who purchased the policy would be disproportionately those who knew they were likely to have high health care costs, and so the company would lose money. To address adverse selection risks, most insurers use medical underwriting and incorporate a risk premium into the actual price of coverage. As a result, the price of health insurance that a typical person would face in the individual market greatly exceeds the average cost of covering him or her. Moreover, a significant proportion of individuals may be uninsured because they are denied coverage as a result of medical underwriting.
See Economic Case at 17.
In addition, and significantly, CEA also noted that “[i]mperfections in credit markets reduce the ability of households, especially low-income households, to obtain goods and services with immediate costs but long-term benefits. Health insurance is a classic example of such a good. Similarly, the uninsured obtain some free medical care through emergency rooms, free clinics, and hospitals, which reduces their incentives to obtain health insurance.” Id. Finally, CEA also noted that “positive externalities” (benefits of healthcare insurance coverage that accrue not to the policyholder but to society in general) “is another force that works in the direction of causing too few individuals and households to have health insurance.” Id.
8. Most individuals make economic decisions whether to attempt to pay for their anticipated health care needs through insurance, or to attempt (often unsuccessfully) to pay out-of-pocket. In making these decisions, individuals weigh the cost of insurance against the cost of their potential out-of-pocket expenses. See Mark V. Pauly, Risks and Benefits in Health Care: The View from Economics, 26 Health Affairs 653, 657-58 (2007) (Ex. 11). Plaintiff Brown weighs whether purchasing insurance for herself will be a “worthwhile cost of doing business.” Am. Compl. ¶ 62.
Response: Plaintiffs dispute the statements in this paragraph that “most individuals make economic decisions whether to attempt to pay for their anticipated health care needs through insurance, or to attempt (often unsuccessfully) to pay out-of-pocket.” This constitutes
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Defendants’ self-serving characterization of some individuals having, and others lacking, healthcare insurance coverage, and also is a legal conclusion rather than a statement of fact.
Moreover, Defendants’ cited authority does not support such a generalized claim, and is without foundation. This paper is not based upon empirical data, but constitutes theoretical discussion of “the economic views of risk” and how that may be applied to individual decision-making about health care. In particular, the author discusses application of the “expected utility” (“EU”) model of decision-making in this area, noting that it “is at best a useful caricature describing general tendencies,” and that “{i]ts value is really comparative. Does it do a better job of explaining or evaluating decisions in general than some other model, including the null hypothesis that people make choices at random?” 654-55.
It is undisputed that the Individual Mandate will compel Plaintiff Mary Brown, like other NFIB members, “to divert resources from their business endeavors, or otherwise to reorder their economic circumstances, in order to obtain qualifying healthcare coverage, regardless of their own conclusions on whether or not obtaining and maintaining such coverage for themselves and their dependents is a worthwhile cost of doing business.” Am. Compl. ¶ 62.
9. Individuals regularly revisit these economic decisions whether to purchase insurance or attempt to finance their health care needs through another manner. Movement in and out of insured status is “very fluid.” Of those who are uninsured at some point in a given year, about 63 percent have coverage at some other point during the same year. CBO, How Many People Lack Health Insurance and For How Long? 4, 9 (May 2003) (Ex. 12); see also CBO, Key Issues, at 11.
Response: Plaintiffs dispute Defendants’ characterization of the presence or absence of healthcare insurance as an economic decision and any implication that having or not having healthcare insurance makes individuals constant participants in the healthcare services or healthcare insurance market. Defendants’ assertions as to what “individuals” may “regularly” do are speculative, and merely constitute Defendants’ characterization of the phenomenon noted by CBO that, in the 1990’s, many who did not have healthcare insurance at some point during the year also had such insurance at some other point during the year.
10. The vast majority of the population — even of the uninsured population — has participated in the health care market by receiving medical services. See June E. O’Neill & Dave M. O’Neill, Who Are the Uninsured?: An Analysis of America’s Uninsured Population, Their Characteristics, and Their Health 20-22 (2009) (Ex. 8) (94 percent of even long-term uninsured have received some level of medical care); see also National Center for Health Statistics, Health, United States, 2009, at 318 (2010) (for 2007, 62.6 percent of uninsured at a given point in time had at least one visit to a doctor or emergency room within the year) (Ex. 9).
Response: It is undisputed that most individuals will, as some point in their lives, receive medical services. Plaintiffs dispute any inference that this makes anyone who has received (or will receive) healthcare services a constant or continuing participant in the market for health care services or for healthcare insurance.
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11. About 20 percent of the population accounts for 80 percent of health spending, with the sickest one-percent accounting for nearly one-quarter of health expenditures. H.R. Rep. No. 111-443, pt. II, at 990.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph, except to admit that it is contained in the cited report. However, the statement is irrelevant and immaterial to the constitutionality of the Individual Mandate. H.R. Rep. No. 111-443, pt. II speaks for itself.
12. Insurers have sought to exclude those they deem most likely to incur expenses. 47 Million and Counting: Why the Health Care Marketplace Is Broken: Hearing Before the S. Comm. on Finance, 110th Cong. 51-52 (2008) (statement of Mark Hall, Professor of Law and Public Health, Wake Forest Univ.) (Ex. 13). That is, they adopt practices designed — albeit imperfectly — to “cherry-pick healthy people and to weed out those who are not as healthy.” H.R. Rep. No. 111-443, pt. II, at 990 (internal quotation omitted).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authorities, the first of which is without foundation. However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
13. These practices include medical underwriting, or the individualized review of an insurance applicant’s health status. This practice is costly, resulting in administrative fees that are responsible for 26 to 30 percent of the cost of premiums in the individual and small group markets. ACA §§ 1501(a)(2)(J), 10106(a). Medical underwriting yields substantially higher risk-adjusted premiums or outright denial of insurance coverage for an estimated one-fifth of applicants for individual coverage, a portion of the population that is most in need of coverage. CBO, Key Issues, at 81.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authorities. However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
14. Before the ACA, health insurance company practices also included: denial of coverage for those with pre-existing conditions, even minor ones; exclusion of pre-existing conditions from coverage; higher, and often unaffordable, premiums based on the insured’s medical history; and rescission of policies after claims are made. Id. As a result, “many who need coverage cannot obtain it, and many more who have some type of insurance may not have adequate coverage to meet their health care needs.” Health Reform in the 21st Century: Insurance Market Reforms: Hearing Before the H. Comm. on Ways and Means, 111th Cong. 53 (2009) (Linda Blumberg, Senior Fellow, Urban Inst.) (Ex. 14). Insurers often revoke coverage even for relatively minor pre-existing conditions. Consumer Choices and Transparency in the Health Insurance Industry: Hearing Before the S. Comm. on Commerce, Science & Transp., 111th
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Cong. 29-30 (2009) (Karen Pollitz, Research Professor, Georgetown Univ. Health Policy Inst.) (Ex. 15).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authorities, which are without foundation. However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
15. More than 57 million Americans have some pre-existing medical condition, and thus, absent reform, were at risk for the denial or rescission of insurance coverage. Families USA Foundation, Health Reform: Help for Americans with Pre-Existing Conditions 2 (2010) (Ex. 16).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authority, which is without foundation. However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
16. Insurers operate in interstate commerce and can gauge their participation in state markets based on the nature of regulation in each state. See Sara Rosenbaum, Can States Pick Up the Health Reform Torch?, 362 New Engl. J. Med. e29, at 3 (2010) (Ex. 17).
Response: The statement that “[i]nsurers operate in interstate commerce” is a legal conclusion rather than a statement of fact. It is undisputed that insurance regulations often differ from State to State. However, these statements are irrelevant and immaterial to the constitutionality of the Individual Mandate.
17. Congress found that the widespread inability of Americans to obtain affordable coverage, or to obtain coverage at all, has significant additional economic effects.
Response: The ACA speaks for itself. Plaintiffs dispute that Congress’s findings bind the Court or render the Individual Mandate constitutional.
18. 62 percent of all personal bankruptcies are caused in part by medical expenses. ACA §§ 1501(a)(2)(G), 10106(a).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph, except to admit that it is contained in the citied ACA provisions. Plaintiffs dispute that Congress’s findings bind the Court or render the Individual Mandate constitutional. Moreover, the averment is irrelevant and immaterial to the constitutionality of the Individual Mandate.
19. The uncertainty that many Americans experience as to whether they can obtain coverage constrains the labor market. The phenomenon of “job lock,” in which employees avoid changing employment because they fear losing coverage, is widespread. Employees are 25 percent less likely to change jobs if they are at risk of losing health insurance coverage in doing so. The
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Economic Case, at 36-37; see also Gruber, Public Finance and Public Policy 431.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authorities, the second of which is without foundation. However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
20. Insurance industry reform to guarantee coverage would alleviate “job lock” and increase wages, in the aggregate, by more than $10 billion annually, or 0.2 percent of the gross domestic product. The Economic Case 36-37.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authority, which is without foundation. However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
21. One result of industry practices that deny, impede, or raise the cost of insurance coverage is that many millions of people are uninsured. In the aggregate, the uninsured shift much of the cost of their care onto other persons. The uninsured continue to receive health care services but pay only a portion of the cost. Jack Hadley et al., Covering the Uninsured in 2008: Current Costs, Sources of Payment, and Incremental Costs 2008, 27 Health Affairs w399, w411 (2008) (Ex. 20); CBO, Key Issues, at 114; see also CBO, Nonprofit Hospitals and the Provision of Community Benefits 1-2 (2006) (Ex. 21).
Response: The statements in this paragraph are irrelevant and immaterial to the constitutionality of the Individual Mandate. However, it is nevertheless disputed that, as stated in sentence 3 of paragraph 21, “the uninsured continue to receive health care services but pay only a portion of the cost.” Defendants have not established that all, or even a significant portion, of the uninsured receive services for which they only partially pay. Plaintiffs also dispute Defendants’ suggestion that uninsured individuals are continuously receiving health care services such that they are always engaged in “economic activity” rendering the healthcare services or healthcare insurance market subject to regulation by Congress. In addition, Defendants’ own authority, which is without sufficient foundation, makes clear that 75 percent of the unpaid costs of treating the uninsured are covered by government programs designed to meet these costs and states that “cost shifting to private insurance finances a relatively small amount of uncompensated care. Private insurance premiums are at most 1.7 percent higher because of the shifting of costs of the uninsured to private insurers in the form of higher charges.” Jack Hadley, et al., at w411.
22. This phenomenon is not limited to the uninsured with the lowest incomes. On average, uninsured persons with incomes of more than 300% of the federal poverty level pay for less than one half of the cost of the medical care that they receive. Herring, 24 J. of Health Econ. at 229-30.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authority, which
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is without foundation. However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
23. The costs of “uncompensated care” for the uninsured fall on other participants in the health care market. In the aggregate, that cost-shifting amounted to $43 billion in 2008, about 5 percent of overall hospital revenues. CBO, Key Issues, at 114. Indeed, this figure may underestimate the cost-shifting. One study estimated that the uninsured in 2008 collectively received $86 billion in care during the time they lacked coverage, including $56 billion in services for which they did not pay, either in the form of bad debts or in the form of reduced-cost or free charitable care. Jack Hadley et al., Covering the Uninsured in 2008: Current Costs, Sources of Payment, and Incremental Costs 2008, 27 Health Affairs w399, w411 (2008) (Ex. 20); CBO, Key Issues, at 114; see also CBO, Nonprofit Hospitals and the Provision of Community Benefits 1-2 (2006) (Ex. 21).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authorities, the second of which is without foundation. However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
24. These costs are in part paid by public funds. For example, through Disproportionate Share Hospital (“DSH”) payments, the federal government paid for tens of billions of dollars in uncompensated care for the uninsured in 2008 alone. Congress determined that preventing or reducing cost-shifting would lower these public subsidies. H.R. Rep. No. 111-443, pt. II, at 983; see also The Economic Case, at 8.
Response: It is undisputed that some costs of medical care for uninsured individuals are met through State and or federal programs designed to pay such costs. Plaintiffs dispute that Congress’s determinations in this respect bind the Court. Moreover, the statements in this paragraph are irrelevant and immaterial to the constitutionality of the Individual Mandate.
25. Other costs fall in the first instance on health care providers, who in turn “pass on the cost to private insurers, which pass on the cost to families.” ACA § 1501(a)(2)(F), 10106(a). This cost-shifting effectively creates a “hidden tax” reflected in fees charged by health care providers and premiums charged by insurers. CEA, Economic Report of the President 187 (Feb. 2010) (Ex. 18); see also H.R. Rep. No. 111-443, pt. II, at 985 (2010); S. Rep. No. 111-89, at 2 (2009) (Ex. 19).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authorities. Plaintiffs dispute the characterization of the “cost-shifting” claimed as a “hidden tax.” However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
26. When premiums increase as a result of cost-shifting by the uninsured, more people who see themselves as healthy make the economic calculation not to buy, or to drop, coverage. For many, this economic calculation leads them to wait to obtain coverage until they grow older, when they anticipate greater health care needs. See CBO, Key Issues, at 12 (percentage of
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uninsured older adults in 2007 was roughly half the percentage of uninsured younger adults); see also M.E. Martinez & R.A. Cohen, National Center for Health Statistics, Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January-June 2009, at 2 (Dec. 2009) (Ex. 22); U.S. Census Bureau, Census Population Survey, Annual Social and Economic Supplement (2009) (Table H101, data on coverage status by age) (Ex. 23).
Response: Plaintiffs dispute the averments in this paragraph as Defendants’ characterizations of phenomena described in the cited authorities. The averments are, in any case, irrelevant and immaterial to the constitutionality of the Individual Mandate.
27. This self-selection further narrows the risk pool, which, in turn, further increases the price of coverage for the insured. The result is a self-reinforcing “premium spiral.” Health Reform in the 21st Century: Insurance Market Reforms 118-19 (2009) (American Academy of Actuaries); see also H.R. Rep. No. 111-443, pt. II, at 985.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that they are contained in the citied authorities, the first of which is without foundation. However, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate. H.R. Rep. No. 111-443, pt. II speaks for itself and does not bind the Court.
28. This premium spiral particularly hurts small employers, due to their relative lack of bargaining power. See H.R. Rep. No. 111-443, pt. II, at 986-88; The Economic Case, at 37-38; see also 47 Million and Counting 36 (Raymond Arth, Nat’l Small Business Ass’n) (noting need for insurance reform and minimum coverage provision to stem rise of small business premiums).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to admit that high healthcare insurance premium costs can hurt small employers. Plaintiffs dispute any implication that the ACA can or will reduce those costs. The Court is not bound by the first authority cited and the second lacks a sufficient foundation. In any case, the averments in this paragraph are irrelevant and immaterial to the constitutionality of the Individual Mandate.
29. To address the economic effects of these market failures, as well as to protect consumers, the ACA comprehensively “regulates activity that is commercial and economic in nature: economic and financial decisions about how and when health care is paid for, and when health insurance is purchased.” ACA §§ 1501(a)(2)(A), 10106(a).
Response: The averments contained in this paragraph constitute legal conclusions and argument. Plaintiffs dispute Defendants’ characterization of the purpose and effect of the ACA. Plaintiffs also dispute that the Individual Mandate “regulates activity that is commercial and economic in nature: economic and financial decisions about how and when health care is paid for, and when health insurance is purchased.” To the contrary, the Individual Mandate regulates inactivity by compelling individuals to obtain healthcare insurance when they do not want it. It is further disputed that mere “decisions” are a form of “economic activity” subject to Congressional regulation. “Factual” findings in the ACA §§ 1501(a)(2)(A) and 10106(a) do not bind the Court.
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30. The minimum coverage provision “is an essential part of this larger regulation of economic activity,” and its absence “would undercut Federal regulation of the health insurance market.” Id. §§1501(a)(2)(H), 10106(a).
Response: Plaintiffs admit that the Individual Mandate is so functionally interdependent with other key aspects of the ACA, including its Medicaid transformation, as to render it unseverable. Plaintiff deny that the absence of the Individual Mandate would prevent Congress from regulating the healthcare insurance market. Plaintiffs also dispute that “findings” in the ACA §§1501(a)(2)(H), 10106(a) in any way bind the Court or render the Individual Mandate constitutional.
31. By “significantly reducing the number of the uninsured, the requirement, together with the other provisions of this Act, will lower health insurance premiums.” Id. §§ 1501(a)(2)(F), 10106(a).
Response: The averments in this paragraph are irrelevant and immaterial to the constitutionality of the Individual Mandate and are speculative. They are based on congressional “findings” that do not bind the Court and which cannot render the Individual Mandate constitutional.
32. Without the minimum coverage provision, the reforms in the Act, such as the ban on denying coverage or charging more based on pre-existing conditions, would amplify existing incentives for individuals to “wait to purchase health insurance until they needed care,” thereby further shifting costs onto third parties. Id. §§ 1501(a)(2)(I), 10106(a). The minimum coverage provision “is essential to creating effective health insurance markets in which improved health insurance products that are guaranteed issue and do not exclude coverage of pre-existing conditions can be sold.” Id.
Response: See response to No. 30, supra. The averments contained in this paragraph constitute argument or legal conclusions. Plaintiffs also dispute that “findings” in the ACA §§1501(a)(2)(I), 10106(a) in any way bind the Court or render the Individual Mandate constitutional.
33. The new “guaranteed issue” and “community rating” requirements under section 1201 of the Act ensure that all Americans can obtain coverage subject to no coverage limits and despite the pre-existing conditions they may have at that time. ACA § 1201. Because these new insurance regulations would allow individuals to “wait to purchase health insurance until they needed care,” id. §§ 1501(a)(2)(I), 10106(a), they would increase the incentives for individuals to “make an economic and financial decision to forego health insurance coverage” until their health care needs become substantial, id. §§ 1501(a)(2)(A), 10106(a).
Response: The averments contained in this paragraph constitute argument or legal conclusions. Plaintiffs dispute the characterization of an individual’s having or not having healthcare insurance as an “economic and financial decision.” Plaintiffs also dispute that “findings” in the ACA §§1501(a)(2)(A), 10106(a) in any way bind the Court. Moreover, the averments regarding the purpose and effect of section 1201 of the ACA are irrelevant and immaterial to the constitutionality of the Individual Mandate. They are based on
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congressional “findings” that do not bind the Court and which cannot render the Individual Mandate constitutional.
34. Individuals who would make that decision would take advantage of the ACA’s reforms by joining a coverage pool maintained in the interim through premiums paid by other market participants. Without a minimum coverage provision, this market timing would increase the costs of uncompensated care and the premiums for the insured pool, creating pressures that would “inexorably drive [the health insurance] market into extinction.” Health Reform in the 21st Century: Insurance Market Reforms 13 (Uwe Reinhardt, Ph.D., Professor of Political Economy, Economics, and Public Affairs, Princeton University).
Response: The averments contained in this paragraph are speculative and constitute argument or legal conclusions. Plaintiffs dispute the characterization of an individual’s having or not having health insurance as an “economic and financial decision.” The cited authority is without foundation and cannot render the Individual Mandate constitutional.
35. This danger is not merely theoretical, but is borne out in the experience of states that have attempted “guaranteed issue” and “community rating” reforms without an accompanying minimum coverage provision. After New Jersey enacted a similar reform, its individual health insurance market experienced higher premiums and decreased coverage. See Alan C. Monheit et al., Community Rating and Sustainable Individual Health Insurance Markets in New Jersey, 23 Health Affairs 167, 168 (2004) (Ex. 25) (describing potential for “adverse-selection death spiral” in a market with guaranteed issue); see also Health Reform in the 21st Century: Insurance Market Reforms 101-02 (Dr. Reinhardt).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to the extent that it is undisputed that the cited authorities, which are without sufficient foundation, contain the stated claims. However, the averments in this paragraph are irrelevant and immaterial to the constitutionality of the Individual Mandate.
36. Likewise after New York enacted a similar reform, “the market for individual health insurance in New York has nearly disappeared.” Stephen T. Parente & Tarren Bragdon, Healthier Choice: An Examination of Market-Based Reforms for New York’s Uninsured, Medical Progress Report, No. 10 at I (Manhattan Institute, Sept. 2009) (Ex. 26).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to the extent that it is undisputed that the cited authority, which is without sufficient foundation, contains the quoted statement. However, the averments in this paragraph is irrelevant and immaterial to the constitutionality of the Individual Mandate.
37. In contrast, Massachusetts enacted “guaranteed issue” and “community rating” reforms, coupled with a minimum coverage provision. Since 2006, the average individual premium in Massachusetts has decreased by 40 percent, compared to a 14 percent increase in the national average. Jonathan Gruber, Mass. Inst. of Tech., The Senate Bill Lowers Non-Group Premiums: Updated for New CBO Estimates, at 1 (Nov. 27, 2009) (Ex. 27); see also Letter from Mitt H.
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Romney, Governor of Massachusetts, to State Legislature at 1-2 (Apr. 12, 2006) (Ex. 28) (signing statement for Massachusetts bill, noting need for insurance coverage requirement to prevent cost-shifting by the uninsured).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph, except to the extent that it is undisputed that Massachusetts enacted the provisions claimed and that the statement regarding that program’s effect is contained in the cited authority, which is without sufficient foundation. Moreover, the averments are irrelevant and immaterial to the constitutionality of the Individual Mandate.
38. In short, “fundamental insurance-market reform is impossible” if the guaranteed-issue and community-rating reforms are not coupled with a minimum coverage provision. Jonathan Gruber, Getting the Facts Straight on Health Care Reform, 316 New Eng. J. of Med. 2497, 2498 (2009) (Ex. 29). This is because “[a] health insurance market could never survive or even form if people could buy their insurance on the way to the hospital.” 47 Million and Counting, at 52 Prof. Hall). Accordingly, Congress found that the minimum coverage provision is “essential” to its broader effort to regulate health insurance industry underwriting practices that have prevented many from obtaining health insurance. ACA §§ 1501(a)(2)(I), (J), 10106(a).
Response: The averments contained in this paragraph constitute argument or legal conclusions. It is undisputed that the quoted statements are contained in the cited authorities, which are without sufficient foundation. Plaintiffs dispute that “fundamental insurance market reform is impossible” without the Individual Mandate. Plaintiffs dispute that the “findings” in ACA §§ 1501(a)(2)(I), (J), 10106(a) bind the Court or render the Individual Mandate constitutional.
39. The minimum coverage provision also addresses the unnecessary costs created by the insurance industry’s practice of medical underwriting. “By significantly increasing health insurance coverage and the size of purchasing pools, which will increase economies of scale, the requirement, together with the other provisions of this Act, will significantly reduce administrative costs and lower health insurance premiums,” and is therefore “essential to creating effective health insurance markets that do not require underwriting and eliminate its associated administrative costs.” ACA §§ 1501(a)(2)(J), 10106(a).
Response: The averments contained in this paragraph constitute argument or legal conclusions and are speculative. Plaintiffs dispute that the “findings” in ACA §§ 1501(a)(2)(J), 10106(a) bind the Court or render the Individual Mandate constitutional.
II. Defendants’ Asserted Facts Pertaining to the ACA’s Amendments to Medicaid 40. The CBO estimates that, under the ACA, federal Medicaid outlays will increase by $434 billion, and state outlays by $20 billion, through 2019. Letter from Douglas W. Elmendorf, Director, CBO, to the Hon. Nancy Pelosi, Speaker, U.S. House of Representatives tbl.4 (Mar. 20, 2010) (Ex. 32) [hereinafter CBO Letter to Speaker Pelosi].
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Response: The CBO Letter to Speaker Pelosi speaks for itself. It is undisputed that these averments are contained in the cited authority. Other federal estimates indicate that the CBO significantly underestimate the impact on both State and federal governments. The Congressional Research Service (CRS) notes that estimates vary based on assumptions of participation. See Pl.App. Ex. 36 (“Variation in Analyses of PPACA’s Fiscal Impact on States,” Congressional Research Serv., September 8, 2010) at tbl. 2. CRS cites projections prepared by Kaiser Commission researchers that predict up to $43 billion in additional State costs and $532 billion in federal costs, assuming a 75 percent uptake rate in the expansion population and lower participation by persons currently eligible for Medicaid, but who are not enrolled.1 CRS also notes that the CBO did not provide information on its assumptions when publishing the estimates cited here by Defendants. Certainly, projections vary as to how many tens of billions of dollars the ACA’s Medicaid program will cost the States in the immediate future, but not that the program will cost the States substantially more money over-and-above current spiraling projections.
41. The CBO estimates that, under the ACA, the federal government will shoulder more than 95 percent of all new Medicaid spending through 2019. See CBO Letter to Speaker Pelosi tbl.4.
Response: CBO Letter to Speaker Pelosi speaks for itself. This averment is inaccurate because, while it may be true that the federal government will shoulder more than 95 percent of the costs of caring for the new, mandated expansion populations, this is not true as to “all” new Medicaid spending through 2019. For example, many current eligibles who enter the program because of the Individual Mandate will be covered at the current, non-ACA federal match rate, and this is certainly “new” Medicaid spending from the States’ perspective. See, e.g., Pl.App. Ex. 1 (Dudek Decl.) ¶ 18 (calculating a $574 million/year cost due to the new enrollment of current eligibles). That is, but for the Individual Mandate, many current eligibles would not have enrolled and States do not set their budgets based on the assumption that this group will enroll.2 Similarly, there is a great deal of other “new Medicaid spending”
1 A higher uptake rate is consistent with the Centers for Medicare and Medicaid Services’
(CMS) view that “the great majority” of new eligibles – 15 million of the 18 million new Medicaid eligibles – “would become covered in the first year, 2014, with the rest covered by 2016.” Pl.App. Ex. 39 (Richard S. Foster, Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” CMS, April 22, 2010) at 6.
2 See, e.g., Kaiser Family Foundation, Financing New Medicaid Coverage Under Health Reform: The Role of the Federal Government & States, at 3 (May 2010), available at http://www.kff.org/healthreform/upload/8072.pdf (describing that the “welcome mat effect” is expected to “be even more marked [than in prior circumstances] because of the broader reach of the legislation and the mandate that people purchase coverage”); see also Pl.App. Ex. 1 (Dudek Decl.) ¶ 18 & attach. 1, pp. 5, 6, 12; Pl.App. Ex. 9 (Betlach Decl.) at B.5; Pl.App. Ex. 10 (Casanova Decl.) ¶ 8 & attach. A, p. 5; Pl.App. Ex. 12 (Phillips Decl.) § B.7; Pl.App. Ex. 13 (Anderson Decl.) attach. C, p. 2; Pl.App. Ex. 14 (Chaumont Decl.) exhibit A, pp. 3, 4; Pl.App. Ex. 16 (Willden Decl.) pp. 4-5 & attach (“Health Care Reform Projected Costs”); Pl.App. Ex. 18 (Bowman Decl.) ¶ 13; Pl.App. Ex. 20 (Millwee Decl.) p. 7; Pl.App. Ex. 24 (Sundwall Decl.), ¶ 12; Pl.App. Ex. 40 (Dubberly Decl.) p. 2 (expecting significant costs from the “welcome mat” or “woodwork” effect).
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that will not be shared by the federal government at 95 percent. For example, new and significant administrative expenses are required by the ACA’s changes to Medicaid eligibility processes, which will not be shared at 95 percent.3 Also, the ACA amended the obligation of States not only to pay for medically necessary services, but to provide care and services themselves. ACA § 2304. The shift from ensuring payment to providing care and services is expected to have a significant negative impact on the States’ cost of providing Medicaid services (see PSOMF [Doc. 80-2] ¶ 25), which will not be shared at the 95 percent rate, at least for the care of enrollees who are not part of the expansion population. For these reasons, the Plaintiff States dispute that “all new Medicaid spending” required by ACA will be at a 95 percent federal share rate.
42. The CBO estimates that, under the ACA, any new federal spending, including on Medicaid, will be offset by other revenue-raising and cost-saving provisions. CBO Letter to Speaker Pelosi at 2.
Response: The CBO Letter to Speaker Pelosi speaks for itself. The federal government’s potential to save under the ACA via spending offsets is irrelevant and immaterial to the issue of the constitutionality of the ACA-transformed Medicaid program.
43. The CBO estimates that the Medicaid expansion will increase Medicaid enrollment by about 16 million by 2019. CBO Letter to Speaker Pelosi tbl.4.
Response: The CBO Letter to Speaker Pelosi speaks for itself, and is a modest estimate of increased Medicaid enrollment. CMS projects a larger number of new Medicaid enrollees with “the great majority” (more than 83 percent) being covered in 2014: “Of the additional 34 million people who are estimated to be insured in 2019 as a result of the [ACA], a little more than one-half (18 million) would receive Medicaid coverage due to the expansion of eligibility.” Pl.App. Ex. 39 (Richard S. Foster, Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” Centers for Medicare & Medicaid Servs., April 22, 2010) at 6. CRS notes that estimates vary based on assumptions of participation. The CRS cited estimates prepared by Kaiser Commission researchers predicting an increase of 22.8 million enrollees (assuming a 75 percent uptake rate in the expansion population and lower participation by current eligibles who are not enrolled). See Pl.App. Ex. 36 (Variation in Analyses of PPACA’s Fiscal Impact on States, CRS, Sept. 8, 2010), tbl 2. CRS also notes that the CBO did not provide information on its assumptions when publishing the estimates
3 One study estimates the cost to the States of additional Medicaid administrative
expenses to be upwards of $12 billion through 2020, in addition to $21.5 billion for increased benefits for Medicaid Expansion. See Edmund Haislmaier & Brian Blase, Obamacare: Impact on States, The Heritage Foundation, July 1, 2010, table 2 http://www.heritage.org/research/reports/2010/07/obamacare-impact-on-states; see also John Holahan & Stan Dorn, Urban Inst., What is the Impact of the [ACA] on the States?, at 2 (June 2010) (Def. Ex. 35) (as cited by Defendants (see ¶ 57, infra), also expects the States’ administrative costs to increase); Pl.App. Ex. 2 (Lange Decl.) ¶¶ 5-10; Pl.App. Ex. 10 (Casanova Decl.) attach. A, p. 7; Pl.App. Ex. 16 (Willden Decl.) p. 2 & attach (“Health Care Reform Projected Costs”); Pl.Supp.App. Ex. 2 (Church Decl.) ¶ 5.
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cited by Defendants. As such, there are differences in the projections related to the number of new enrollees, but no dispute that the number will be quite large.
44. Nationally, the Medicaid expansion will reduce by 44.5 percent the number of uninsured adults below 133 percent of the federal poverty level. Kaiser Comm’n on Medicaid & the Uninsured, Medicaid Coverage & Spending in Health Reform, at 10 tbl.1 (May 2010) (Ex. 34).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph, except to admit that it is contained in the cited Kaiser Commission Report. The effect of Medicaid expansion on the number of uninsured adults below 133 percent of the poverty level is irrelevant and immaterial to the constitutionality of the ACA-transformed Medicaid program.
45. In Florida, the federal government is expected to pay for 94.2 percent of the Medicaid expansion through 2019, while the number of uninsured adults below 133 percent of the federal poverty level is expected to decline by 44.4 percent. Kaiser Comm’n on Medicaid & the Uninsured, Medicaid Coverage & Spending in Health Reform, at 10 tbl.1 (May 2010).
Response: Plaintiffs: deny the first averment made in this paragraph; lack knowledge of the figure in the second averment; and admit that these averments are contained in the cited Kaiser Commission Report. The averments in this paragraph are irrelevant and immaterial to the constitutionality of the ACA’s transformation of Medicaid. Florida expects to pay about 13 percent of the cost of the ACA’s expanded Medicaid program through 2019. See Pl.App. Ex. 1 (Dudek Decl.), attach. 1 at 11 [Doc. 80-3 at 27-28]. Moreover, a decrease in uninsureds in that income group will not be caused solely by Medicaid’s expansion. Currently 301,960 Floridians are eligible for Medicaid but are not enrolled.4 See discussion of cost of “woodwork” or “welcome mat” effect, supra, ¶ 41. If they enroll, and thereby reduce the number of uninsured, they will do so because of the ACA’s Individual Mandate, an illness, or other precipitating event; not because of Medicaid’s expansion. Also, if they enroll, this group of previously uninsured people will not be paid for by the federal government at a 94.2 percent rate. If they enroll, their costs will be shared by the federal government at a much lower rate – 57.5 percent. Id.
46. In South Carolina, the federal government is expected to pay for 95.9 percent of the Medicaid expansion through 2019, while the number of uninsured adults below 133 percent of the federal poverty level is expected to decrease by 56.4 percent. Kaiser Comm’n on Medicaid & the Uninsured, Medicaid Coverage & Spending in Health Reform, at 10 tbl.1 (May 2010).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph, except to admit that it is contained in the cited Kaiser Commission
4 See Pl.App. Ex. 1 (Dudek Decl.) attachment 1 (Fla. Agency for Health Care Admin.,
Overview of Federal Affordable Care Act, August 13, 2010).
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Report. The statements in this paragraph are irrelevant and immaterial to the constitutionality of the ACA’s transformation of Medicaid.
47. Compared to baseline projections in the absence of reform, by the end of 2019, average state Medicaid spending under the ACA is expected to increase 1.4 percent. Kaiser Comm’n on Medicaid & the Uninsured, Medicaid Coverage & Spending in Health Reform, at 10 tbl.1 (May 2010).
Response: See ¶ 40, supra. Plaintiffs dispute this averment as it is materially incomplete and constitutes the low estimate made by the Kaiser Commission’s Report. The Kaiser Commission Report provides two projections of State spending and this averment references only the less-likely lower projection. See Pl.App. Ex. 36 (Variation in Analyses of PPACA’s Fiscal Impact on States, Cong. Res. Serv., Sept. 8, 2010) at tbl 2. The Report’s higher projection is for State Medicaid spending to increase by almost 3 percent compared to baseline projections. Id. (based on a 75 percent uptake) CMS’s view would favor use of the higher projection as it expects “the great majority” of new eligibles – 15 million of the 18 million new Medicaid eligibles (more than 83 percent) – “would become covered in the first year, 2014, with the rest covered by 2016.” Pl.App. Ex. 39 (Richard S. Foster, Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” CMS, April 22, 2010) at 6. It is also materially important to analyze this information in view of existing baseline projections, which are for state spending to increase by more than 60 percent – see, e.g., infra, ¶ 60. The ACA exacerbates the States’ very difficult fiscal position by not only increasing their direct costs, but, via unprecedented maintenance of effort provisions (ACA §§ 2001(b) & 2101(b)), also limiting the States’ flexibility to control and cut costs.
48. Many states currently subsidize health care outside of Medicaid, in programs funded entirely with state or local dollars, for individuals that will be eligible for Medicaid under the ACA. Council of Economic Advisers (“CEA”), The Impact of Health Insurance Reform on State and Local Governments, at 4-5 (Sept. 15, 2009) (Ex. 33) [hereinafter “The Impact on States”].
Response: The averments in this paragraph are disputed because they conflate State and local spending, are based on an authority that uses incorrect information without foundation, and are immaterial to the constitutionality of the ACA’s transformation of Medicaid. See Pl.Supp.App. Ex. 4 (Further Dudek Decl.); Pl.Supp.Ap. Ex. 1 (Further Chaumont Decl.); Pl.Supp.App. Ex. 3 (Damler Decl.). This CEA Report predated passage of the ACA by either legislative body by many months and so cannot be considered a viable source of analysis on the ACA’s final terms. This report is seriously flawed. See, e.g., infra, ¶ 56. As such, no post-ACA analysis of State spending obligations by the federal government relies upon or even makes reference to the CEA’s report. See, e.g., Pl.App. Ex. 39 (Richard S. Foster, Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” Centers for Medicare & Medicaid Servs., April 22, 2010); Pl.App. Ex. 36 (Variation in Analyses of PPACA’s Fiscal Impact on States, Cong. Res. Serv., Sept. 8, 2010) at tbl 2; D. Ex. 32 (CBO Letter to Speaker Pelosi).
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The averment conflates the spending of state and local governments. See Pl.Supp.App. Ex. 4 (Further Dudek Decl.); Pl.Supp.App. Ex. 5 (Pridgeon Decl.). Local government spending does not bear on the constitutional question presented in this case, insofar as savings by local governments arising from the expansion of Medicaid would come at the expense of State budgets. Id. Moreover, any current State or local policy to subsidize care will not altogether vanish under the ACA as, even by Defendants’ estimation, Medicaid will not zero-out the number of uninsured adults below 133 percent of the federal poverty level altogether, but merely reduce this population by 44.5 percent. See ¶ 44, supra. The CEA Report upon which Defendants rely forecasts that additional savings “may come” from the Children’s Health Insurance Program (CHIP). Pl.Supp.App. Ex. 1 (Further Chaumont Decl.) ¶ 13. However, under the PPACA no changes to eligibility regarding CHIP can be made until 2019, leaving no mechanism in place for States to manage or reduce this cost. Id. Finally, the CEA Report bases its conclusions on income levels of 133% of the federal poverty line, not 133% with a 5% disregard, as included in the ACA. Pl.Supp.App. Ex. 1 (Further Chaumont Decl.) ¶ 17. As a result the CEA Report does not reflect the current eligibility levels contemplated by the ACA. Id.
49. Pennsylvania subsidizes coverage for adults under 200 percent of FPL through its adultBasic program, at a cost of $172 million in 2008. CEA, The Impact on States, at 85.
Response: See ¶ 48. The statements in this paragraph are irrelevant and immaterial to the constitutionality of the ACA’s transformation of Medicaid.
50. Indiana subsidizes coverage for adults under 200 percent of FPL through its Healthy Indiana Plan, at a cost of $154.8 million in 2009, and separately funded millions in emergency care for the indigent in fiscal year 2010-11. CEA, The Impact on States, at 34-35.
Response: See ¶¶ 48-49. This averment is not projected to provide a savings to offset State costs under the ACA. See Pl.Supp.App. Ex. 3 (Damler Decl.) ¶ 22.
51. Many states, like Pennsylvania and Indiana, currently subsidize health care for some individuals falling between 133 percent and 400 percent of FPL using only state or local funds. CEA, The Impact on States, at 34-35, 85.
Response: See ¶¶ 48-49. This averment is not projected to provide a savings to offset State costs under the ACA. See Pl.Supp.App. Ex. 3 (Damler Decl.) ¶ 22.
52. Many states, including Idaho, Indiana, and Nebraska, currently fund high-risk insurance pools to subsidize coverage for individuals who have been denied private coverage due to pre-existing conditions. CEA, The Impact on States, at 29, 35, 67.
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Response: See ¶¶ 48-49. This averment is not projected to provide a savings to offset state costs under the ACA. See PRO Ex. 6 (Ramge Decl.); PRO Ex. 3 (Damler Decl.). 53. [No entry by Defendants.] 54. Miami-Dade County, Florida, currently funds uncompensated care at public facilities through a 0.5 percent sales tax, which raised $187 million in fiscal year 2007. CEA, The Impact on 13 States, at 24.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph, except to admit that it is contained in the cited CEA Report. See also ¶¶ 48-49. The CEA Report does not specify whether or how much of these dollars (this is a total revenue figure) are spent on people who will be eligible for Medicaid under ACA. It makes unstated and unsupported assumptions about the use of local tax dollars and apparently does not take into account varying uptake rates. Furthermore, local governments will not be in a position to discontinue funding public care facilities because funding still will be needed to fund undercompensated care. Medicaid rates currently pay providers less than 60 percent of what a private insurer would pay for the same service.5 Although mandated to rise under the ACA, reimbursement still will not meet costs, and public hospitals still will need a source of revenue to make up the difference. The net impact is incalculable at this time, but the increases in Medicaid payments are unlikely to offset the Medicare reductions. This will lead to an even greater need for local dollars, not less, to pay for the undercompensated care.
55. It is estimated that, under the ACA, state and local governments will recoup up to $1.6 billion per year of the “hidden tax” that cost-shifting imposes on health insurance premiums for their employees. CEA, The Impact on States, at 6.
Response: The averment in this paragraph is irrelevant and immaterial to the constitutionality of the ACA’s transformation of Medicaid and is disputed. See ¶ 48, supra. The basis for the CEA Report’s conclusion cited in the above averment is a mystery as it does not fully explain its methodology for reaching this conclusion. While some cost-shifting applies to healthcare spending, this figure appears unsupported in the cited document. See Pl.Supp.App. Ex. 1 (Further Chaumont Decl.) ¶¶ 11-12. Moreover, this conclusion misleadingly groups together the spending of State and local governments. Id.; see also Pl.Supp.App. Ex. 4 (Further Dudek Decl.) ¶¶ 8-12; Pl.Supp.App. Ex. 5 (Pridgeon Decl.) ¶¶ 14-16. Local government spending does not bear on the constitutional question presented in this case insofar as “hidden tax” savings by local governments would not result in a savings for State budgets. Id. Local governments employ about three times more persons than State governments. See http://www.census.gov/govs/apes/. To the contrary,
5 Devon Herrick, Medicaid Expansion will Bankrupt the States, National Center for
Policy Analysis, Brief Analysis # 729, October 23, 2010, available at http://www.ncpa.org/pub/ba729 (last visited Nov. 22, 2010).
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record evidence in this case – based on analysis completed after the ACA was passed – shows that the ACA’s employer mandates will increase the Plaintiff States’ expenses for healthcare insurance premiums and not provide a savings. See Pl.App. Ex. 5 (Robleto Decl.) ¶¶ 9-17; Pl.App. Ex. 6 (Shier Decl.) pp 2-3; Pl.App. Ex. 7 (Ashmore Decl.) ¶¶ 7-9; Pl.App. Ex. 8 (Battilana Decl.) ¶¶ 5-9; Pl.App. Ex. 15 (Wells Decl.) ¶¶ 7-10; Pl.App. Ex. 17 (Van Camp Decl.) ¶¶ 4-5; Pl.App. Ex. 19 (Zinter Decl.) ¶¶ 11; Pl.App. Ex. 21 (Dial Decl.) pp. 2-7; Pl.App. Ex. 22 (Kukla Decl.) p. 3.
56. Taken together, the savings that will accrue to states from (1) the downsizing or elimination of duplicative state programs and (2) the reduction in the “hidden tax” on premiums now borne by state governments, are estimated at $11 billion per year after 2013. CEA, The Impact on States, at 6-7. Florida alone is projected to save $377 million per year. Id. at 6, 26.
Response: See ¶¶ 48-55. The Florida-specific $377 million figure is disputed as wholly inaccurate. The large programs cited in the CEA report do not use State dollars, but local government dollars: • More than $256 million that Defendants describe applies to local governments only, not
to the State of Florida’s budget: $187 million for Miami-Dade County, $82 million for Hillsborough County, $660,000 in Duval County, and $5.6 million relating to inter-county reimbursements. See CEA Report at 24, 26. The State of Florida will not see savings from these local government programs financed through local taxes, although the State may see cost increases as persons switch out of such local programs to Medicaid. See Pl.Supp.App. Ex. 4 (Further Dudek Decl.) ¶¶ 8-12; Pl.Supp.App. Ex. 5 (Pridgeon Decl.) ¶¶ 7-16.
• The CEA Report’s “Hidden Tax” ($102 million) figure (pp. 6, 24) erroneously assumes
that the healthcare bill will eliminate uncompensated care altogether. This figure is flawed as Defendants admit, for instance, that 55 percent of current uninsured persons under the federal poverty line will remain uninsured in Florida (DMSJ 82-1] at 39) and 21 million nationally. See Payments of Penalties for Being Uninsured Under the Patient Protection and Affordable Care Act, CBO, April 22, 2010. The CEA Report also bases this estimate on costs borne by both State and local governments, so it is inaccurate to attribute the full $102 million savings estimate to the State of Florida alone.
• The CEA Report forecasts State savings of ($117 million) that “may come” from the
Children’s Health Insurance Program (CEA Report at 24-25). Florida already has taken State CHIP-related savings projections into account in its own forecast (see Pl.App. Ex. (Dudek Decl.) ¶ 20), wherein Florida estimates the ACA will cost it more than $1 billion annually by 2018-19.
57. It is estimated that state and local governments would save approximately $70-80 billion over the 2014-2019 period by shifting currently state-funded coverage into federally matched Medicaid. John Holahan & Stan Dorn, Urban Institute, What Is the Impact of the [ACA] on the States?, at 2 (June 2010) (Ex. 35).
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Response: The statements in this paragraph are irrelevant and immaterial to the constitutionality of the ACA’s transformation of Medicaid and also are disputed. The authority cited by Defendants is without foundation. This report is unreliable because: it does not explain its data sources and conflates the spending of State and local governments. Pl.Supp.App. Ex. 5 (Pridgeon Decl.) ¶¶ 16. Local government spending does not bear on the constitutional question presented in this case, insofar as savings by local governments arising from the expansion of Medicaid would come at the expense of State budgets. See Pl.Supp.App. Ex. 4 (Further Dudek Decl.) ¶¶ 8-12; Pl.Supp.App. Ex. 5 (Pridgeon Decl.) ¶¶ 7-16; Pl.Supp.App. Ex. 1 (Further Chaumont Decl.) ¶¶ 8-12. Moreover, any current State or local policy to subsidize care will not altogether vanish under the ACA as, even by Defendants’ estimation, Medicaid will reduce the number of uninsured adults below 133 percent of the federal poverty level by merely 44.5 percent. Moreover, a CRS publication of several States’ estimates indicates that six States a total of more than $38 billion in increased enrollment costs. See Pl.App. Ex. 36 (Variation in Analyses of PPACA’s Fiscal Impact on States, Cong. Res. Serv., Sept. 8, 2010), tbls 1 & 2. This CRS report shows varying impacts, including one state which anticipates some savings, but no offsets proportional to a national magnitude of $70-$80 billion. Id.
58. It is estimated that states’ savings from no longer having to finance as much of the cost of providing uncompensated care to the uninsured may fully offset the increase in Medicaid costs resulting from the Medicaid expansion. J. Angeles, Center on Budget and Policy Priorities, Some Recent Reports Overstate the Effect on State Budgets of the Medicaid Expansions in the Health Reform Law, at 10 (Oct. 21, 2010) (Ex. 36).
Response: The statements in this paragraph are irrelevant and immaterial to the constitutionality of the ACA’s transformation of Medicaid and also disputed. The authority cited by Defendants is without foundation. See ¶ 57 (Angeles’ cites to Holahan’s (Urban Institute) estimate).
59. Increases in federal Medicaid funding will generate economic activity at the state level, including jobs and state tax revenues. Kaiser Family Foundation, Health Reform Issues: Key Issues About State Financing and Medicaid, at 3 (May 2010) (Ex. 37).
Response: The statements in this paragraph are irrelevant and immaterial to the constitutionality of the ACA’s transformation of Medicaid. It is also speculative and inconsistent with various paragraphs above in which Defendants insist that federal spending will merely shift tens of billions of dollars in state spending to the federal government. Also, increases in State Medicaid funding will require significant funding cuts to other programs or new revenues. Cuts to other programs may have negative economic effects, suggesting that any economic increase due to State and federal Medicaid spending increases may be offset by loss of State spending elsewhere. CMS, Medicaid Spending Projected to Rise Much Faster Than the Economy, http://www.hhs.gov/news/press/2008pres/10/20081017a.html (last visited Nov. 23, 2010) (CMS’s Acting Administrator acknowledged that “[h]igh and increasing Medicaid spending clearly leaves States less able to fund other state priorities”).
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Similarly, increased taxes or fees to support State Medicaid spending would have an adverse effect on the Florida economy, which may offset any economic increase due to State and federal Medicaid spending increases. See Pl.App. Ex. 3 (Watkins Decl.); Christina D. Romer, Back to a Better Normal: Unemployment and Growth in the Wake of the Great Recession, Council of Economic Advisors, April 17, 2010 at 9 (suggesting that tax increases would only compound the States’ fiscal dilemma and that aid to the States was given for the very purpose of keeping them from raising taxes),
60. Absent reform, state Medicaid/CHIP spending is estimated to increase 60.7 percent by 2019 even under the best-case scenario. Bowen Garrett et al., Urban Institute, The Cost of Failure to Enact Health Reform: Implications for States, at 13 tbl.2B (Sept. 30, 2009) (Ex. 38).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph, except to admit that it is contained in the cited Urban Institute Report. This Report speaks for itself. CMS projected a baseline increase in spending projections at an annual average rate of 7.9 percent through 2019 (and 9.9 percent just in 2009). CMS, National Health Expenditure Projections 2009-2019, at 1-2, https://www.cms.gov/NationalHealthExpendData/downloads/proj2009.pdf (last visited Nov. 10, 2010). Importantly, however, more than 60 percent of Medicaid spending is considered optional spending that has not been mandatory for states and, until the ACA, could be cut if necessary to control costs. See Anna Sommers, Medicaid Enrollment and Spending by “Mandatory” and “Optional” Eligibility and Benefit Categories, Kaiser Comm'n on Medicaid & the Uninsured, June 2005, at 11. The ACA’s maintenance of effort provisions lock States into significant, formerly optional Medicaid spending.
61. There is a “great deal of variation across states in terms of Medicaid coverage, the uninsured, state fiscal capacity, leadership, and priorities.” Kaiser Comm’n on Medicaid & the Uninsured, Medicaid Coverage & Spending in Health Reform, at 1 (May 2010).
Response: The Kaiser Commission Report speaks for itself. Whatever the variations, they are irrelevant and immaterial to the constitutionality of the ACA’s transformation of Medicaid.
62. In fiscal year 2008, federal Medicaid grants ranged from $246 million (Wyoming) to $23.8 billion (New York). Kaiser Family Foundation, Federal & State Share of Medicaid Spending, FY2008 (Ex. 39).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph. The Kaiser Commission Report speaks for itself.
63. In fiscal year 2008, federal medical assistance percentages (“FMAPs”) ranged from 50 percent (several states, including Colorado) to 76 percent (Mississippi). 71 Fed. Reg. 69209, 69210 (Nov. 30, 2006).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph. This citation speaks for itself.
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64. In fiscal year 2008, state spending on Medicaid, as a proportion of total state revenues, ranged from 8.4 percent (Alaska) to 34.5 percent (Missouri). Nat’l Ass’n of State Budget Officers, Fiscal Year 2008 State Expenditure Report, at 10 tbl.5 (Fall 2009) (Ex. 40) [hereinafter NASBO Report].
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph. This citation speaks for itself.
65. In fiscal year 2008, the proportion of total state revenues formed by federal Medicaid grants ranged from 4.4 percent (Alaska) to 21.5 percent (Missouri). See NASBO Report at 10 tbl.5; 71 Fed. Reg. at 69210.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averments made in this paragraph. This citation speaks for itself.
66. In fiscal year 2008, Mississippi spent 11 percent of its budget on Medicaid. NASBO Report at 10 tbl.5.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph. This averment appears to be disputed in the table it cites, which provides that 22.4 percent of Mississippi’s total expenditures were for Medicaid.
67. In fiscal year 2008, Pennsylvania spent more than 30 percent of its budget on Medicaid. NASBO Report at 10 tbl.5.
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph. This citation speaks for itself.
68. Many states, including Florida, provide subsidized care outside of Medicaid, funded entirely with state or local dollars. CEA, The Impact on States, at 23-26.
Response: See ¶¶ 48-56. 69. The vast majority of states collect personal income, corporate income, and sales taxes. Fed’n of Tax Adm’rs, 2009 State Tax Collection by Source (Ex. 42).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph. This citation speaks for itself.
70. Six plaintiff states (Alaska, Florida, Nevada, South Dakota, Texas, and Washington) impose no personal income tax. Fed’n of Tax Adm’rs, 2009 State Tax Collection by Source.
Response: This citation speaks for itself.
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71. Three plaintiff states (Nevada, Texas, and Washington) impose no corporate income tax. Fed’n of Tax Adm’rs, 2009 State Tax Collection by Source.
Response: This citation speaks for itself. 72. One plaintiff state (Alaska) imposes no sales tax. Fed’n of Tax Adm’rs, 2009 State Tax Collection by Source.
Response: This citation speaks for itself. 73. Of the 10 states in the nation with the lowest per capita tax burden, 7 are plaintiffs here (Alabama, Arizona, Colorado, Florida, Georgia, South Carolina, South Dakota, and Texas). Fed’n of Tax Admins., 2009 State Tax Revenue (Ex. 43).
Response: This citation speaks for itself. 74. Between 1966 and 2000, Medicaid enrollment expanded from 4 million to 33 million. John Klemm, Ph.D., Medicaid Spending: A Brief History, 22 Health Care Fin. Rev. 106 (Fall 2000) (Ex. 31).
Response: Plaintiffs lack knowledge or information sufficient to admit or deny the averment made in this paragraph, which is irrelevant and immaterial to the constitutionality of the ACA’s Medicaid program. Moreover, the statement is misleading to the extent that it would ascribe enrollment expansion to vast changes in Medicaid’s eligibility terms over the years. For example, all 50 states participated in Medicaid in 2000, but many did not participate in 1966 (the inaugural year). Furthermore, more than 60 percent of Medicaid spending is considered optional spending that was not mandatory for States during these years. See Anna Sommers, Medicaid Enrollment and Spending by “Mandatory” and “Optional” Eligibility and Benefit Categories, Kaiser Comm'n on Medicaid & the Uninsured, June 2005, at 11. The ACA transforms the Medicaid program from its traditional bounds as a partnership to assist poor and needy persons to one that locks States into providing services for those in formerly optional eligibility categories and requires States to cover approximately 20 million more higher-income persons (83.9 million persons within Medicaid & CHIP programs) virtually overnight. See Pl.App. Ex. 39 (Richard S. Foster, Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” Centers for Medicare & Medicaid Servs., April 22, 2010) at 3. This figure represents more than one-quarter of the U.S. population. See http://www.census.gov/compendia/statab/2010/tables/10s0002.pdf.
Respectfully submitted,
BILL MCCOLLUM ATTORNEY GENERAL OF FLORIDA
/s/ Blaine H. Winship Blaine H. Winship (Fla. Bar No. 0356913) Special Counsel
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Joseph W. Jacquot (Fla. Bar No. 189715) Deputy Attorney General Scott D. Makar (Fla. Bar No. 709697) Solicitor General Louis F. Hubener (Fla. Bar No. 0140084) Timothy D. Osterhaus (Fla. Bar No.
0133728) Deputy Solicitors General Office of the Attorney General of Florida The Capitol, Suite PL-01 Tallahassee, Florida 32399-1050 Telephone: (850) 414-3300 Facsimile: (850) 488-4872 Email: [email protected] Attorneys for Plaintiff States David B. Rivkin (D.C. Bar No. 394446) Lee A. Casey (D.C. Bar No. 447443) Baker & Hostetler LLP 1050 Connecticut Avenue, N.W., Ste. 1100 Washington, DC 20036 Telephone: (202) 861-1731 Facsimile: (202) 861-1783 Attorneys for Plaintiff States, National Federation of Independent Business, Mary Brown, and Kaj Ahlburg Katherine J. Spohn Special Counsel to the Attorney General Office of the Attorney General of Nebraska 2115 State Capitol Building Lincoln, Nebraska 68508 Telephone: (402) 471-2834 Facsimile: (402) 471-1929 Email: [email protected] Attorneys for Plaintiff the State of Nebraska Karen R. Harned Bill Cobb Executive Director Deputy Attorney General for National Federation of Independent Civil Litigation Business Office of the Attorney General of Texas Small Business Legal Center P.O. Box 12548, Capitol Station 1201 F Street, N.W., Suite 200 Austin, Texas 78711-2548 Washington, DC 20004 Telephone: (512) 475-0131 Telephone: (202) 314-2061 Facsimile: (512) 936-0545 Facsimile: (202) 554-5572 Email: [email protected]
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Of counsel for Plaintiff National Attorneys for Plaintiff the State of Texas Federation of Independent Business
CERTIFICATE OF SERVICE I hereby certify that, on this 23rd day of November, 2010, a copy of the foregoing
Plaintiffs’ Response to Defendants’ Statement of Facts As to Which There Is No Genuine Issue
was served on counsel of record for all Defendants through the Court’s Notice of Electronic
Filing system.
/s/ Blaine H. Winship Blaine H. Winship Special Counsel